CHAPTER 8 Overview of Radiographic Quality e e e e e e e CHAPTER OBJECTIVES 1. Define “radiographic quality.” 2. Differentiate between “high-quality” and “poor-quality” radiographs. 3. List the four qualitative factors. 4. Define: density, contrast, definition, and distortion. KEY WORDS AND TERMS. Quality radiograph Definition Density Distortion Contrast RECOMMENDATIONS FOR GENERAL DISCUSSION QUESTIONS 1. Explain the concept of film qualitative factors, 2. How does each of the factors listed below affect the quality of the image? Density Definition Contrast Distortion. 737A RADIOGRAPHIC IMAGING Quality relates to the characteristics of an object and indicates the degree of excellence that the object may exhibit. A high-quality radiograph is a radio- graph with all factors at optimum. Quality identifies, the amount of information available for reviewing the radiograph. Radiographers must be able to evaluate the qual: ity of a radiograph by visual inspection. To many radiographers, quality is often too abstract and hard to measure. The “art” of radiography is the ability of the radiographer to work with concepts and characteristics present on a finished radiograph in order to measure the degree of excellence. A high-quality radiograph is one that demon: strates the specific anatomie part of interest with a sharp image and with the appropriate amount of blackening (density) distributed over the film. It is a radiograph with a sufficient distribution of film blackening that provides excellent subject contrast. ‘The image has been recorded with the least possible magnification and distortion of the actual size and shape of the anatomic part, Fig, 8-1 shows two radiographs, one with poor quality and one with excellent quality FIGURE 8-1. Rov mut be uate th radiograph. Penetration is adequat Fadiograph, There ts too much blackening A HIGH-QUALITY RADIOGRAPH MUST HAVE. ‘A SHARP IMAGE WITH ADEQUATE DENSITY, AND CONTRAST ‘To evaluate the degree of quality, a radiographer_ must be able to assess density, contrast, definition, and distortion. The factors are controlled and af- fected by the selection of technique components and the use of radiographic accessories. DENSITY Radiographic density is the blackening on the finished radiograph (Fig. 8-2). Tt is produced by - development of exposed silver halide erystals in the film emulsion. The prime factor that controls film density is milliampereseconds (mAs). As discussed in the previous chapter, film density is also affected - by the kilovoltage (kVp) selection.A FIGURE 8-2. RADIOGRAPHIC DENSITY IS THE OVERALL BLACKENING ON THE FILM. DENSITY IS. CONTROLLED BY mAs. CONTRAST Radiographic contrast is the second quality factor Contrast represents a variation in density levels across the film and serves to make anatomic detail visible. Contrast is also described as a distribution of different density values. The function of contrast is to make structural detail visible. CONTRAST MAKES DETAIL VISIBLE Contrast also refers to a range of density levels that can range from very dark (black) to areas on the radiograph with little or no density (clear or white). The prime factor that controls contrast is kVp (Fig. 8-3 CONTRAST IS THE VARIATION IN DENSITY LEVELS THAT MAKES DETAIL VISIBLE CONTRAST IS CONTROLLED BY KILOVOLTAGE. OVERVIEW OF RADIOGRAPHIC QUALITY 75 DEFINITION ‘The third quality factor is definition. Definition refers to the clarity and distinctness of the fine structural lines or borders of anatomic parts. To produce a radiograph with good definition, one must give careful attention to these aspects: selection of the focal-film distance (FFD); focal spot size; place- ment and alignment of the tube, part, and film; the amount of exposure to the film; and the use of adequate kVp and accessories that help control the amount of scatter radiation reaching the film. Each of the factors mentioned above contributes to the production of a radiograph with good definition (F' 8-4), ee DEFINITION REFERS TO THE CUARITY AND? SHARPNESS OF THE STRUCTURAL LINES OP THE ANATOMIC PARTS. ———— DISTORTION, ‘Phe fourth -quality:factonis distortion. This factor indicates an andesired-change.in. the size and/or shape of the anatomic part has occurred in. the process of imaging. the parts Distortion: mistepres76 RADIOGRAPHIC IMAGING 4, A radiograph of the abdomen. Contrasts present, with diferent density levels making entre surface of te film. Although density is present, there i FIGURE 8-3. Radiographs wit contra the anatomic parts visible mpletely black across thOVERVIEW OF RADIOGRAPHIC QUALITY A FIGURE 8-4. Two radi the cervical spine. 4 shows the cervical vertebrae; however, the blurred and unsharp. In 6, the borders ofthe individual vertebrae are very clear and sharp, a FIGURE 8-5. 4, & radiograph ofthe hand with minimal di The fingers appear shorter and the bones ofthe wrist re Su78 — RADIOGRAPHIC IMAGING ‘TABLE 8-1, THE RELATIONSHIP OF QUALITATIVE AND, TECHNICAL FACTORS, Related Technical Factor Quality Factor Control Influence Density mas Wp FO Contrast kv Definition FFD. lp mAs Distortion FD. sents.the size andior shape of the objeet,-and the i ‘The prime factors-associated-with distortion are placement of the tube, the part, and-the film (Fig. 8-5). DISTORTION IS THE MISREPRESENTATION OF THE SIZE AND/OR SHAPE OF THE ANATOMIC | PART OF INTEREST. — Table 8-1 represents a summary of the four quality factors and their relationship to the tech-— nical factors. TABLE 8-2. RADIOGRAPHIC QUALITY Del Recorded Detail Distortion Visibility of Detail Focal spot size ‘Alignment of Density (mAs) Focal-film distance (FFD) part Contrast kVp) Object-fiim distance (OFD) lm Scatter radiation Motion tube Grids Screens FD. Beam restriction oFD Understanding the relationship between quality and the technical factors is essential for radiogra- phers. To successfully practice their skills, radiog- raphers work with technieal and quality factors and the combination of these factors. To many radiographers, quality is an abstract term, Understanding the quality factors gives ra- diographers the tools to evaluate radiographs. To better understand the quality concept, review Table 8-2. As demonstrated in this table, the umbrella for radiographic quality is definition. All factors support the process of producing high-quality radio- graphic images. The concept of radiographic quality is described in detail in the following chapters.CHAPTER 9 Radiographic Density CHAPTER OBJECTIVES Define radiographic density. Write the formula that expresses radiographic density. Describe the difference in density for areas on a radiograph that are black and clear Explain how exposure to the film affects density. Differentiate between radiographic film density and tissue (object) density, and explain the relation- ship. Define densitometer and describe its function Identify the optical density range for medical radiography Define attenuation. Explain how attenuation of the primary x-ray beam affects density Name the major technical factors that control density. 11. Explain the relationship between mAs and density. 12. Explain how kVp affects density. 13. Describe how the following will affect density: Syene Distance (FFD) Tissue characteristics Anode heel effect Pathology Filters Equipment calibration Processing Grids Film-screen systems Beam restriction Fog 14. Evaluate radiographs to determine if adequate density is present KEY WORDS AND TERMS. Density Attenuation Opaque mAs-distance relationship Blackening on the film Density-distance relationship Tissue density kVp-density relationship Pathology Anode heel effect Foreign body density Equipment calibration Contrast media density Screen conversion factor Densitometer Filters Density formula Compensating filters Optical density range 79RECOMMENDATIONS FOR GENERAL DISCUSSION QUESTIONS. 1. Define radiographic density with the formula: L D = Logi What criteria should a radiographer use to evaluate radiographic density? Explain attenuation and how it affects the formation of the image. Name the factor used to control density, and provide supporting information. Identify and discuss at least 10 factors that will affect the amount of density recorded on the film. 80Radiographic density is the opacity of the radio- graph or its inability to be penetrated by light. As described in previous chapters, radiographic density is defined as the blackening on the film. Radio- graphs are like overhead transparencies used in classroom instruction. Clear areas allow light to shine through, and more opaque areas absorb light and prevent the light from coming through (Fig. 9-1) RADIOGRAPHIC DENSITY IS THE OPACITY OF THE RADIOGRAPH, ALSO DESCRIBED AS THE AMOUNT OF BLACKENING ON THE FILM. RADIOGRAPHIC DENSITY 81 After a radiograph has been processed, it is ex: amined by placing it on a viewbox’(Fig. 9-2). The viewbox is a wall-mounted or portable device with fluorescent light bulbs that is covered with white transparent material. The transparent cover causes the light to be diffused evenly across the viewing surface. The degree of optical opaqueness on the radio- graph is density. When a radiograph is placed on ‘the viewbox, the light can be seen coming through in some areas where less density (blackening) is present, and some areas are found with little or no density (clear‘white). Little or no light will come through the areas with more density. The increase in density on the film causes these areas to be more opaque. : FIGURE 9-1, Density is blackening on the film, a/Difer@ht/G6ReHeS are distributed across the film producing an image"oF WE WNORAK. 8, A Processed film with no density present; C. afm with the density level the same across the entire Surface of the fil ‘ooritle density to visualize the part of interest, and represents a radiograph with sufficient density iograph in D has =82 RADIOGRAPHIC IMAGING. FIGURE 9-2. Radiographs ona lighted viewbox. The Density is given a general definition of the black. on the radiograph. The blackening is the of processing the latent or invisible image a visible image. The amount of exposure from x-rays and the light from the intensifying screen determine the amount of blackening that is present after development of the image THE AMOUNT OF EXPOSURE REACHING THE FILM DETERMINES THE AMOUNT OF DENSITY ON THE FINISHED RADIOGRAPH. Density is the characteristic of the radiograph that is described as a photographie or optical qual: ity. A radiograph is @ permanent photographic re cord: 1 cence of density and the many different density-levels across the surface of the film make the image visible, Because density defines the com- pleteness of the image, it becomes the key to radio- graphic interpretation. The part of interest must be visualized with the appropriate levels of density to make it-visible. Other quality factors depend on the presence of proper density, Without the proper den sity, the other factors of definition may lose their significance because the film is useless. reas with less density allow more light to pass through WITHOUT PROPER DENSITY, OTHER FACTORS MAY LOSE THEIR SIGNIFICANCE, RADIOGRAPHIC FILM DENSITY VERSUS TISSUE DENSITY It is important to differentiate the word density as it is used in the medical sciences. Density is also, used to describe the nature of tissue, such as bone, characteristics of contrast media, and foreign bodies. The bones of the skeleton are more dense than muscle; Teeth are more dense than bone, and lung tissue is much less dense than either bone, teeth, or muscle (Fig. 9-3). Contrast: media, such as bar ium, will change tissue density and increase attem- uation of the beam: Foreign bodies, such as metallic objects, will also change the attenuation of the beam, producing an outline of the object on the radiograph. The study of anatomy and physiology is necessary to be able to discern tissue density levels throughout the body. Tissue density is important in radiography in the recording of proper radiographic density. As stated earlier, radiographic density is necessary to make the image visible. Tissues of greater density, suchair Vegetable _ ol water J Bone A FIGURE 9-3. 4 radiograph made with test tubes filled with a small bone sample, water, tissue components ofthe body. 8, A radiograph made with an orange and hand phantom, Variation in tissue density forthe four basi as bone, require more exposure in order to visualize the markings and characteristics on the radiograph. In radiography, we categorize tissue into five major Broups: aerated tissue, fatty tissue, water, bone, and teeth. As shown in Figure 9-3, aerated tissue such as the lungs has the least tissue density and requires a small amount of exposure to record the appropri- ate level. of density. Fatty. tissue is the next»to lowest level of tissue density. Third is tissue with a high water content such as muscle. Bones and teeth are the most.dense tissue in. the body and require the greatest amount of exposure to record appropri: ate density levels on the radiograph. Fig. 9-3B shows a radiograph of a hand phantom and an orange. The hand phantom demonstrates a greater variation in tissue densities than the orange. MEASUREMENT OF DENSITY Radiographic density is a quality factor that can be measured with an instrument called a densitom- eter (Fig. 9-4), THE DENSITOMETER IS AN INSTRUMENT USED. TO MEASURE DENSITY ee ‘The densitometer contains a light source with a known amount of illumination. The light source is RADIOGRAPHIC DENSITY 83 at (vegetable oll, and alr. This example shows the covered with a translucent material containing a very small pinhole. The pinhole allows light to pass through the cover without hitting any absorbing material. The area of interest on the radiograph to be measured is placed over the pinhole, and a reading probe is placed exactly on the area for measurement: The. instrument then reads the amount of light passing through the radiograph at the specific point of interest. The readings are te- corded in logarithms (Fig. 9-5), For measurement purposes, radiographic density is defined as the logarithm (base 10) of the ratio of light hitting the film to the amount of light trans- mitted through the film! L, represents the light FIGURE 9-4. Densitometer used to measure radiographic density84 RADIOGRAPHIC IMAGING FIGURE 9-5. against the lm, The optical density reading is iven in a logan. hitting the film and is a known standard. Ly repre- sents the amount of light transmitted (Fig. 9-6). With the use of a densitometer, one may measure density levels on any area of the radiograph. (Remember, these numbers are logarithms, so the range is ac- tually very broad.) Incident = Film Formula is D=Los is FIGURE 9-6. Measuring density on the radiograph, IN RADIOGRAPHY, DENSITY READINGS ARE MOST USEFUL BETWEEN 0.25 AND 2.00. Transmited ATTENUATION AND DENSITY | Attenuation means a reduction in strength or force. As the x-ray photons travel through the body, they are attenuated (absorbed) by tissue structures. X-ray beam before attenuation Photon loses energy as tpasses through sa Attenuated beams tha form the image gis FIGURE 9-7. Attenuation of the x-ray beam as it passes throush an object causes the beam to weaken and lose energy. Because the beam is attenuated more by ticker parts, less photon energy is present to expose the film. Areas of the film under thicker body parts have less density.‘As the photon beami emerges from the body to strike the film, it is no longer a uniform beam like the primary beam. Areas of the beam with almost complete attenuation produce very little radio- graphic density and the parts of the beam with very little attenuation produce areas of greater optical density on the finished radiograph. ATTENUATION IS THE REDUCTION IN STRENGTH OR FORCE. Attenuation causes the radiograph to represent the body part in terms of different density levels. Without attenuation, the end result would be a film with the same density level across the entire surface (Fig. 9-7) ATTENUATION OF THE BEAM CAUSES. DIFFERENT DENSITY LEVELS TO BE PRESENT ON THE RADIOGRAPH. The degree to which body parts attenuate the beam affects density. Bone attenuates the beam more than muscle or fatty tissue. Areas of the film under bone receive very little exposure and there- fore have less radiographic density. Bones are dem- onstrated by light areas on the radiograph. Lung tissue and gas in the intestinal tract attenuate the beam much less and are demonstrated by darker areas on the radiograph (Fig. 9-8). CONTROLLING FACTORS FOR DENSITY Density on a radiograph is primarily controlled by the milliampereseconds (mAs). Distance (focal- film distance [FFD)) can also be used to control density; however, distance variables are eliminated as much as possible to help produce consistent results. Distance (FFD) is standardized in most radiology departments and eliminated as a control- ling factor for density. Changing the distance (FFD) is not practical because the image definition would also be affected, This concept is explained in Chap- ter 11 Changing the mAs is the radiographer’s prime method used to control the blackening on the film. The mAs is the factor that controls the number of photons in the x-ray beam (Fig. 9-9), RADIOGRAPHIC DENSITY 85 FIGURE 9-8. Air or gas in the gastrointestinal tract altenuates thé beam lessthan does skeletal tissue. As ilustrated here, gas shadows are present in the small and large intestine as areas of increased density. DENSITY IS CONTROLLED BY mas. The relationship between mAs and density is directly proportional. If the mAs is doubled, the amount of density recorded on the film is doubled. If the mAs is reduced by one half, the amount of density recorded is reduced by one half. THE RELATIONSHIP BETWEEN mAs AND. DENSITY IS DIRECTLY PROPORTIONAL. The more photons available as the beam exits the body, the more exposure the film receives. As the mAs is increased, the x-ray film receives more exposure. The sensitivity specks in the film emul- sion will attract more silver ions, and when the film is developed, the amount of black metallic silver deposits will increase. This produces an increase in blackening on the film. ‘AS THE mAs IS INCREASED, THE FILM. RECEIVES MORE EXPOSURE.86 RADIOGRAPHIC IMAGING. 200 mas -400mAS A. 5 eh eee Photons exposing the fm (A) Photons exposing the fm 8) FIGURE 9-9. Changing the mAs from 200 to 400 will double the density on the film. The number of photons exposing the film will increase, producing more blackening on the fil, The maximum density level that is photographi-_ cally useful is 2.00. Measurements of 3.0-plus may be obtained, but at this level, it is not important to the radiographer. The naked eye can not differen- tiate density levels in this range. Once total black- ness on the film occurs, all silver in the emulsion has been changed to black metallic silver. To con- tinue the exposure will have no advantage on optical density because the maximum optical density has previously been achieved. In the photographic range, to see a visible difference in density on a radiograph, one must increase the mAs by at least 30 to 35%. TO SEE A VISIBLE CHANGE IN DENSITY, ONE MUST INCREASE THE mAs BY AT LEAST 30 TO 35%, KILOVOLTAGE AND DENSITY Iv is important to understand that although mAs is the primary factor used to control density, kilo- voltage changes can also significantly affect density on the film, An increase in kilovoltage peak (kVp) will result in an increase in density recorded on the film. The relationship between kVp and radio- graphic density is not one of proportion, ‘An increase in kVp increases the penetrating ability of the beam. The density distribution changes, producing a radiograph with a different appearance as a result of the different density levels, ‘The 15% rule is used to predict changes in density levels with kVp. An inerease in kVp by 15% will approximately double the overall density on the film. By using this rule, a change of more than 10 kVp would be needed at higher kVp settings, whereas at lower kVp settings, small changes of only 4 to 5 kVp may be needed (Fig. 9-10).FIGURE 9-10, Kilovoltage changes will affect density produced using 70 kVp and & wa the increase n kilovoltage A 15% INCREASE IN kVp WILL APPROXIMATELY DOUBLE THE DENSITY ON THE FILM. When kVp is increased, more scatter radiation is produced, which adds density on the film. Scatter will also produce more fog across the film. When only a change in density is required to improve a radiograph, the most effective factor is milliam- pereseconds. AS kVp INCREASES, MORE SCATTER RADIATION IS PRODUCED AND EXPOS! FILM, THUS INCREASING DENSITY. S THE SECONDARY FACTORS THAT AFFECT DENSITY Milliampereseconds (mAs) is the major factor used to control density. In addition, kVp changes also have a significant effect on recorded density Other factors that affect density are the anode heel effect, equipment calibration and operation, proc- A ancy Dera duced using 81 kVp (all other fa RADIOGRAPHIC DENSITY 87 hs kilovoltage is increased by 15%. A was ors remained the same). The density level in Bis greater as a result of essing of the latent image, film type, screen type and speed, characteristies of the part to be radio- graphed, filters, Potter-Bucky diaphragm (grids), beam restriction, and fog (all types). Anode Heel Effect X-rays originate from the focal spot area and travel in all directions. In radiography, the useful beam consists of those photons exiting from the focal spot area and traveling through the tube port or window. The physies of x-ray production demon- strate that a variation in intensity is present when one measures the intensity on the anode and cath- ode side of the x-ray beam. The intensity of the beam is less on the anode side of the beam. Figure 9-11 demonstrates the anode structure. The lower ‘most portion of the anode is described as the heel. THE ANODE HEEL EFFECT CAUSES THE BEAM INTENSITY TO BE LESS ON THE SIDE OF THE ANODE. ——————— Photons move from their origin through the target to become part of the primary beam. The loss in intensity is a result of traveling further through88 RADIOGRAPHIC IMAGING. r\ ines FAURE 9-1. Anode sect The lowermost potion of the ane Cees the sen a he hel The ange of th anode res fo he lower edge of the target and identifies the size of the angle. Anode angles range from 8 to 20 degrees. Focal spot the anode heel portion of the target. This is called the anode heel effect and results in photons with slightly lower intensity on the anode side. Measurement of the primary beam on the cathode and anode sides will demonstrate this phenomenon. Radiographers must recognize the anode heel effect and act to overcome any possible effects on the film. A larger field size and a shorter FFD will produce ‘a more noticeable anode heel effect on the finished radiograph. ‘The angle of the anode structure will also affect the presence of the anode heel effect. The heel effect, will increase with a decrease in the anode angle (Fig. 9-12). To overcome the density changes that result from the anode heel effect, the radiographer places the thicker body parts under the cathode side of the tube, with thin body parts under the anode side, as, shown in Figure 9-13. Longer focal-film distance (FFD) and smaller field sizes will reduce the con- sequences of the anode heel effect. Maintenance of the x-ray equipment is necessary for consistency in exposure. Density can be severely. affected (plus or minus) by poorly calibrated equip- ‘ment. Proper selection of factors and proper opera- tion are also essential. Radiographers must under- stand how to select exposure factors, especially the use of time and milliampere (mA) factors. At the time of exposure, radiographers must be able to determine if full exposures are obtained. The re- cording of proper density depends upon the knowl- edge and skill of the radiographer in the use of the x-ray equipment. Processing of the Latent Image ‘The time-temperature relationship is important in processing radiographs to show optimum density. Solution temperatures that are too hot will increase density, and temperatures that are too low will produce radiographs with insufficient density. Con- taminated processing chemicals and improperly pre- pared chemicals can also affect density levels by increasing fog levels, which are undesirable on the film. | Film Type Film types that contain increased amounts of silver halide crystals will increase density. Care must be taken by the radiographer to prevent over- exposure or too much density. Slower film build less density and require an adjustment in the exposure factors. Radiographers must be aware of the film type that they are using to produce the radiograph Screen Type — Intensifying sereens increase density on the film by intensifying the action of the x-rays. As the screen speed increases, the density will increase; therefore, less exposure will be needed to keep density at the appropriate level. Speed of the screen’ and its impact on density are important factors with the rare earth systems, which are much faster than calcium tungstate screens (compare the examples of speed factors as given in Table 5-1). The reduction in exposure necessary with rare earth screens) "greatly reduces the amount of radiation exposure toy Characteristics of Tissue ‘The structure and composition of body tissue may affect density by changing attenuation. More denseRADIOGRAPHIC DENSITY 89" \ Db Xray a Anode hee area J) Angle ot “ Angle of Ve anode ~~ anode é eae Anode se Caode side A 8 c 25° FFD Cathode ae se side Density ~ 0.68 Density = 0.93, 30" FFD node Cathode Density = 0.55, Density = 084. D FIGURE 9-12. A and B represent anode targets with 17° and 10° angles. C illustrates how the x:fay photons produced as the electrons strike the focal spot area travel in all diectons. The heel effect results ftom a decrease in photon intensity as photons eavelfurter tweush the hel of the anode before they ext the target. The primary beam has slightly lower intensity on the anode side. The angle of the anode will see influence the anade heel efect, with a decrease in the angle of the anode increasing the heel effect. The hee effect will be greser with 0 to anode angle than with a 17° anode angle. D, Radiographs demonstrating the anode heel effect. The top exposure (#1) was sade uae 2 25 FED. The collimator was opened as wide as possible with the long axis Of the tube. The transverse shutters of the beam restrictor were ited to produce an image about 3" wide. The anode is located to the left and the cathode to the right. The density measurements wwe 0.68 ay te ‘anode side and 0.93 on the cathode side. The lower image (#2) was produced using the same beam restriction technique but with» 30° FA, The density measurement on the anode side of the exposure is 0.55. On the cathode side, the density reading is 0.84, A clover examington reveals an image with increased density on the cathode side ofthe exposure90 RADIOGRAPHIC IMAGING. ‘anode [=f = cathode = J Anode Cathode ace se FIGURE 9-13. Density chang be overcome by placing the thickest part unde the way tube, as illustrated here or compact structures will absorb more of the x-ray photons as they pass through the tissue. Less radia tion will exit the part to strike the film, and density will be decreased. Soft tissue, such as the anatomic parts of the gastrointestinal tract, will absorb less radiation, and these areas may appear darker (or show more density) than the areas representing bone. THE STRUCTURE AND COMPOSITION OF BODY TISSUE MAY AFFECT DENSITY BY CHANGING THE ATTENUATION OF THE BEAM. Pathologic processes may also affect the recording. of density on the film, For example, destructive processes of the skeleton may be demonstrated by increased density readings. Bone tissue that has heen destroyed by a disease process, resulting in less radiation absorption, will be demonstrated by an area of increased density on the radiograph Figure 9-14 demonstrates examples of density changes as a result of pathology changes. Radiog- raphers must study pathologic processes in order to understand how diseases change body tissues. To compensate, exposure factors must be decreased for destructive diseases such as emphysema or osteo- porosis, and exposure factors must be increased for diseases that cause an increase in tissue density. FIGURE 9-14. as a result of dis \ shows an area of increased tssue density inthe right lung, issue density. B shows a pathologic Fracture of the humerus disease. The radiographic density increased owing t0 the ase, Radiographic density is d Around the fracture are areas of decreased tissuAdjustment of the exposure factors is necessary to maintain proper density on the radiograph CHANGES IN TISSUE DENSITY DUE TO. PATHOLOGIC PROCESSES MUST BE COMPENSATED FOR WITH A CHANGE IN THE EXPOSURE FACTORS TO MAINTAIN ADEQUATE DENSITY, ‘Filters Filters are thin aluminum or metal devices that are located between the x-ray tube and beam re- Strietion device. The purpose of filtration is to absorb the low-energy x-ray photons in the beam as they exit the tube. The low-energy photons contribute nothing to the radiograph; however, these low- energy photons greatly increase the patient's skin dose of absorbed radiation. To protect the patient, filtration is required; Compensating filters are an added filtration to provide a more overall uniformly exposed radio- graph. For example, the femur with surrounding tissue is a body part that is usually significantly thicker at the proximal end. With the use of a wedge-type filter (Fig. 9-15), the exposure to the film will be more evenly distributed. For a detailed discussion of filters, refer to Chapter 12. COMPENSATING FILTERS ARE ADDED TO PROVIDE A MORE UNIFORMLY EXPOSED RADIOGRAPH. Compensation filters can be very effective when one is imaging body parts with great variation in tissue thickness. Grids (Potter-Bucky Diaphragm) Grids are used to absorb some of the scatter and secondary radiation produced by the body parti The grid is placed between the patient and the film. Scatter and secondary radiation account for up to 50 to 90% of the density on a radiograph. Grids) improve the quality of the film by absorbing scatter radiation. ‘The absorption of radiation causes a re- duction in the total amount of radiation reaching. RADIOGRAPHIC DENSITY = Wedge titer Concave fiter (A) (8) FIGURE 9-15. Compensating fiters are added to produce a primary beam that ill provide a more uniform exposure tothe film. A. The \wedke filter can be used with the thick part placed over the thin part ofthe anatomy. B, The concave fiter would be useful in radiography ofthe thorax on the film. In other words, the addition of a grid will reduce density. The use of a grid requires an in- crease in exposure factors to maintain adequate density levels on the radiograph. For example, to change from a non-grid exposure to a grid exposure requires approximately four times the original ex- posure to keep film density constant. A more de- tailed discussion of grids is found in Chapter 14. GRIDS ARE USED TO DECREASE THE DENSITY. ON THE FILM PRODUCED BY SCATTER RADIATION. Beam Restriction Beam restriction devices are used to restrict the beam field size to the size of the part. Collimators) are the most common type of beam restricti Cones and aperture diaphragms are alternate types of beam restriction. Beam restriction devices reduce the field size and the actual area exposed on the patient by the primary radiation beam, As the field size decreases, smaller areas are exposed and less scatter radiation is produced. The result is less TABLE 9-1. FACTORS AFFECTING DENSITY Tafa Controlling Factor ing Factor Milliampereseconds(nA5 Kilovoltage (kVp) Tissue thickness Tissue density Foreign bodies Contrast media Distance (FFD) Scatter radiation Anode heel effect Processing Equipment operation Filmscreen systems Filters Grids Beam restriction Fos92 RADIOGRAPHIC IMAGING. density recorded on the film. Compensation of ex- posure factors is necessary to maintain the proper density level on the radiograph. For example, if the field size is reduced from a 14 x 17 film size to a 10 x 12 film size, the mAs must be increased approximately 35% to keep the density constant. BEAM RESTRICTION DECREASES DENSITY ON THE FILM BY REDUCING THE AMOUNT OF SCATTER RADIATION. Fog (All Types) Fog is increased or unwanted density on the radiograph. It is undesirable and a detriment to the quality of the film. The main source of fog on radiographs is scatter radiation. Table 9-1 sum- marizes the factors that control and influence den- sity. FOG IS INCREASED DENSITY ON THE RADIOGRAPH.CHAPTER 10 Radiographic Contrast CHAPTER OBJECTIVES 20. Define radiographic contrast Explain the relationship between density and contrast. Explain how tissue absorption affects contrast. Describe how attenuation affects contrast. Identify the major technical factor that controls radiographic contrast. Describe the function of contrast. Discuss the relationship between mAs and contrast List two types of contrast in radiography. Describe how contrast media and pathologic processes affect contrast. Discuss the inherent factors that affect film contrast. Differentiate between long scale and short scale of contrast. Differentiate between high contrast and low contrast. Write the terms that refer to long scale of contrast. Write the terms that refer to short scale of contrast. Explain how the kVp selection affects long scale, short scale, high degree or high contrast, and low contrast. Define the phrase “moderate scale of contrast.’” List the disadvantages for a scale of contrast that is too long or too short. Describe the criteria for evaluating a radiograph for adequate contrast. Explain how the following will affect contrast Film-screen systems — Grids Rare earth screen Beam restriction Processing Tissue compression Evaluate radiographs to determine if adequate contrast is present. KEY WORDS AND TERMS Radiographic contrast Low contrast Tissue contrast High degree of contrast Film contrast Low degree of contrast kVp-contrast relationship Exposure latitude Penetration of the part Moderate scale of contrast Underpenetration of the part Grids Long scale of contrast Beam restriction Short scale of contrast Pathologic conditions High contrast 93RECOMMENDATIONS FOR GENERAL DISCUSSION QUESTIONS What is the function of contrast? Discuss the importance for adequate film density to achieve optimal contrast on the film. How does beam attenuation affect contrast? Create an outline for explaining the terminology associated with contrast using the following: BYR Long scale High contrast Short scale Low contrast High degree More contrast Low degree _Insufficient contrast 5. Explain how each characteristic of contrast identified in #4 is achieved by manipulation of technical factors and/or accessories. 6. What are the criteria for the evaluation of a radiograph for optimal contrast? 94The second important quality factor and property of a radiograph is contrast. Density must be present in order for one to visualize contrast. Is it possible to have density on a radiograph without the pres- ence of contrast? The answer is “yes.” If the entire surface of the film has been exposed to a uniform, amount of x-radiation and/or fluorescent light from, the intensifying screens, the result will be a radio- graph that has the same density level over the entire surface of the film (Fig. 10-1) DENSITY MUST BE PRESENT IN ORDER FOR ONE TO VISUALIZE CONTRAST. Is it possible to have contrast present on a radio- graph without the presence of density? The answer s “no.” Contrast on a radiograph depends on the presence of density. Contrast is the difference in density between two structures. Contrast ean be high with sharp differ- ences in dark and light areas, or low with very little differences between densities. The presence of con- trast means that different density levels are visible on the radiograph. The density levels on a radio- graph are multiple, ranging from light (almost clear) to dark areas (black) (Fig. 10-2) Contrast can also be identified as the ratio of radiation intensity as it exits a specific type of tissue to radiation intensity exiting an adjacent type of tissue. For example, the amount of radiation strik- ing the film as it exits the area of the lung tissue measured 20 milliroentgens (mR) and the amount measured as the radiation exits the area of the heart is 8 mR. In this generalized example, the lungs would have more exposure and would be shown to be a darker area when compared with the adjacent heart shadow, where less remnant radia- tion exited the part to strike the film. Contrast is present, and the radiologist would then be able to distinguish the heart shadow from the surrounding, Tung tissue (see Figure 10-10) Contrast is important on a radiograph because it functions to make structural detail visible. The radiologist must be able to see detail with visible borders present. Contrast is the factor that makes the borders of the anatomic structures visible as well as the fine details within the object. THE FUNCTION OF CONTRAST IS TO MAKE DETAIL VISIBLE. RADIOGRAPHIC CONTRAST 95 Radiographic contrast can also be described as a variety of density levels distributed across the film. In reviewing Figure 10-1, we see that A shows a radiograph with no contrast present. The level of density is uniform across the entire surface of the film. Figure 10-1B and D show radiographs with two and three density levels present. A block of paraffin wax, which has a uniform composition, was radiographed, producing an image with basically two levels of density. Contrast is present inasmuch as the block of paraffin is readily visible with a darker density border. The radiograph in Figure 10-1C shows a routine posterior-anterior chest radiograph with many different levels of density distributed across the film. Contrast is present, which permits the visualization of the lungs, heart, ribs, diaphragm, ete. ATTENUATION AND CONTRAST — Attenuation is a reduction in strength or force as a result of absorption and interactions. As the x-ray photons travel through body tissue, they are atten- uated. The result is an x-ray beam that is no longer uniform, ATTENUATION OF THE BEAM IS A. REDUCTION IN STRENGTH OR FORCE DUE TO ABSORPTION AND INTERACTIONS. Contrast is the result of attenuation and the differential absorption of tissue. Without beam at- tenuation, contrast would not be present because a uniform density level would be present. When no absorber has been placed in the beam, the density levels will not change. Figure 10-1 shows how contrast results from beam attenuation. A repre- sents a beam with no attenuation, whereas C rep- resents an attenuated beam with different degrees of absorption as a result of the many different tissue densities. C represents differential absorption of the tissue of the thorax. As you can see, the heart attenuates the beam more than lung tissue. CONTRAST IS THE RESULT OF ATTENUATION AND THE DIFFERENTIAL ABSORPTION IN. TISSUE.96 RADIOGRAPHIC IMAGING fi R h no contrast, Density fe chest. Because multiple levels of densityFIGURE 10-2. Image of ofthe penetrometer ae erent density levels, Because each step attenuates the beam differently owing 0 increased thickness, contrasts visible 80 kVp. The CONTRAST AND SILVER DEPOSITS Another way to describe contrast is the distribu- tion of metallic silver that is present following the development of the latent image. Areas of greater silver deposits have more density and areas with smaller silver deposits will have less density. CONTROLLING FACTOR OF CONTRAST The technical factor that controls contrast is kilo: voltage. The radiologists want to see complete im- RADIOGRAPHIC CONTRAST 97 ages of tissue and not simply a silhouette or outline, Radiographers must produce radiographs that dem. onstrate the structural detail of the tissue. CONTRAST IS CONTROLLED BY KILOVOLTAGE. In order for the radiologist to visualize the desired detail, the part must be adequately penctrated Penetration of the part is controlled by the kilovolt- age. Attenuation and the distribution of densities across the film are significantly affected by the kilovoltage selection. Therefore, the factor used to control contrast is kilovoltage. Figure 10-3 dem- onstrates the importance of kilovoltage. ATTENUATION AND PENETRATION OF THE PART ARE AFFECTED BY CHANGES IN THE kVp. SELECTION. The concept represented in Figure 10-3A dem- onstrates how a lower kilovoltage peak (kVp) selec tion will allow for only thin parts to be penetrated The remaining parts completely attenuate the beam. The x-ray photons are not energetic enough to penetrate the part. The result is demonstrated by the use of a penetrometer in Figure 10-4 The use of an optimal kVp selection is shown in Figure 10-4. As the kVp increases, the photons have sufficient energy to penetrate the multiple thicknesses but with different amounts of attenua- tion. The thickest part is slightly penetrated, and the adjacent layer of thickness attenuates the beam slightly less, distinguishing it from the two layers on either side. The result is the visualization of each layer with only a slight variation in density The tissue structures to be demonstrated must be adequately penetrated in order to have sufficient contrast to make the detail visible. Milliampereseconds (mAs) changes the quantity of photons in the beam and cannot be used a substitute factor to alter contrast on a radiograph. Penetration is not affected by increases or decreases in the mAs. No appreciable amount of increase in beam quantity can make up for a lack of energy of the x-ray photons in the beam. In other words, do not use mAs as the technical factor to produce changes in contrast. Kilovoltage controls contrast and mAs controls density98 RADIOGRAPHIC IMAGING 4 was produced using 45 kVp. B was produced using 88 kVp. A is an FIGURE 10-3. Exposures made with high and low kVp selections Image that mostly black and white, whereas 6 isan image with overall gray tones and many shades of prayRADIOGRAPHIC CONTRAST 99. A B FIGURE 10-4. Radiographs of the pene shades of gray, producin w kilovolt meter made with high a shorter sale of contrast, or high cor selections. A was produced using 50 kVp. There are few using 90 kVp. There are many shades c100 RADIOGRAPHIC IMAGING TYPES OF CONTRAST In diagnostic radiology, two types of contrast are generally recognized: subject or tissue contrast and film contrast. The ability to see skeletal structures on a radiograph is due to the presence of subject contrast. Subject contrast is the difference in density of adjacent structures. Subject contrast is present with bone and its surrounding soft tissue. When one, images the kidneys, ureters, bladder, and gastroin- testinal (GD tract, little or no subject contrast is present. The density differences are not great enough to allow for borders to be visible. If these structures are to be visualized, an external agent called contrast medium must be utilized. For ex. ample, contrast media are injected into the venous system in order to visualize the drainage system of the kidneys (Fig. 10-5) SUBJECT CONTRAST IS THE DIFFERENCE IN DENSITY OF ADJACENT STRUCTURES. The contrast medium has a higher atomic number and will increase attenuation of the beam, resulting in increased subject contrast. Figure 105A shows, a plain radiograph of the abdomen, whereas Figure 10-5B demonstrates how the presence of contrast medium will produce an image of the urinary sys tem, CONTRAST MEDIA CAN BE USED TO INCREASE SUBJECT CONTRAST Subject contrast is controlled by the quality of the x-ray beam. The energy of the photons must be great enough to penetrate the anatomic parts. This, depends on the structure, thickness, and character- istics of the tissue composition. Tissue with greater water content requires more energy to penetrate the part than tissue composed mainly of fat or air. Bone requires greater energy to penetrate than any soft tissue structure in the body. Therefore, when, the combination of these tissue types is present in, the area to be exposed by the primary beam, subject FIGURE 1 5. Contrast of J by the anatomic pat produ fe use of contrast medium, A shows an abdominal radiograph produced without Eoatrat medium, The Kidneys are present owing to their tissue density. Other parts of the urinary system are visualized in B after contrast medium has been injected into the venous system of the patient. Contrast medium enhances the subject contrast to show the drainage system Ureters, and bladdercontrast will be evident. Gas (air) shadows can be seen in the GI tract, and bone with surrounding tissue can be visualized, as demonstrated in Figure 10-6. Pathology is also a factor in subject contrast. Disease processes often change the tissue structures and composition by making them more or less dense ‘These changes can be visualized by subject contrast, if the tissue changes are sufficient. FILM CONTRAST Film contrast refers to those qualities of x-ray film that result in the recording of high contrast or low contrast. The qualities are inherent in the preparation of the emulsion. Fog and scatter affect, film contrast. Fog and scatter are undesirable den- sity that produces gray tones on the film, which decrease contrast. Gas in the intestine: FIGURE 10-6. Subject contast is demonstrated in A with gas inthe large RADIOGRAPHIC CONTRAST 101 FILM CONTRAST IS INHERENT IN THE PREPARATION OF THE FILM EMULSION CHARACTERISTICS OF CONTRAST In order for a radiographer to consistently produce radiographs with acceptable contrast, he or she must be familiar with the use of kilovoltage and the characteristics exhibited on a radiograph. The language of contrast becomes a critical factor. Contrast is described as either long scale, short seale, or moderate scale. Scale refers to the number of different densities present on the radiograph, If a radiograph was cut up into tiny little squares (each representing a density level) and the squares lined up in a graduated column with the lightest stration continued on following page102 RADIOGRAPHIC IMAGING FIGURE 10-6 Continued Skeletal and soft tissue can be seen in 8 square at the top and the darkest square at the bottom, this would represent a scale of contrast (Fig. 10-7), CONTRAST SCALE REFERS TO THE NUMBER OF DIFFERENT DENSITY READINGS PRESENT ON THE RADIOGRAPH Long seale of contrast would be represented by a Jong column, with many squares representing each density level. The change from one square to the next would be gradual (Fig. 10-8). LONG SCALE OF CONTRAST IS REPRESENTED BY MANY DIFFERENT DENSITY LEVELS ON THE RADIOGRAPH. Short scale of contrast would be represented by a column with fewer squares (Fig. 10-88). Fewer density levels would be shown from the lightest to larkest square. The change in density from one square to the next would be more pronounced. SHORT SCALE OF CONTRAST IS REPRESENTED BY ONLY A FEW DENSITY LEVELS ON THE RADIOGRAPH. Long Scale of Contrast Long scale of contrast means the difference in recorded density of adjacent structures is very small, and many density levels are present. There are many different shades of gray between the lightest and darkest density values, Radiographs with a very long scale appear gray (Fig. 10-8A). The advantage of a long scale of contrast is the visualization of more structural detail. Most tissue densities have been penetrated and structural detail is visible. Long seale is a result of higher kilovolt- age: The higher the kilovoltage, the more gray tones are present on the radiograph. Part of the grayness is a result of increased scatter radiation produced by the increase in kilovoltage. The gray appearance produced by long scale reduces the overall contrast, and, in many cases, it is unwanted and undesirable. LONG SCALE OF CONTRAST HAS MANY SHADES OF GRAY AND IS THE RESULT OF HIGH kVp. ‘Terms to describe long scale can be confusing. For example, long scale means low contrast, low degree of contrast, decreased or not enough contrast. Low contrast and low degree of contrast refer to very small density difference from one square to the next, on the scale, “Not enough contrast” is a term used by many who believe a long scale has too many, gray tones and not enough subject contrast (Fig 10-8), Increased exposure latitude is present with long- scale (high-kVp) techniques. Increased exposure lat- itude means that the margin of error is greater for acceptable exposure using high kilovoltage selec- tions and results in a long scale of contrast. Figure 10-9 presents the elements of long scale of contrast.RADIOGRAPHIC CONTRAST 103 Dark Dark o | » a Licht A Light Very few density levels, Many diferent density levels 8 Z Density squares ordered Density squares ordered produce a short scale To produce a tong scale ICMP ce aiNe coro ernst the presence of lara of dandy. To price fe, the small squares ar lined up withthe darkest squares atthe top andthe lightest ones atthe bottom, The result const seal. In A, the le group has only a few shades of density and the group onthe right has many diferent density squares In 8 the squares on te fet have been ordered withthe dark Squares atthe top and the light squares at the bottom. The result Teorganized with the darkest squares atthe top and the prodicing a longer scale of contrast104 RADIOGRAPHIC IMAGING Short Scale of Contrast The opposite of long seale is short scale of contrast. Short scale of contrast is present when the density differences in adjacent structures are abrupt or pronounced. Short scale of contrast is produced by the use of low kVp selections. The column of density levels shown in Figure 10-8B will be short, with few shades of gray tones between the lightest and darkest areas. The borders, of the structures are evident, and, to many, radio. graphs exhibiting a short scale of contrast are better for viewing. The most positive characteristic for short scale is the enhanced contrast shown with skeletal studies (Fig. 10-10) Long scale—Low contrast High kVp image latitude A FIGURE 10-8. Long scale versus short scale. , Long scale of contr B, Short scale of contrast has fewer density levels between the li Low degree of contrast Not enough contrast Increased exposure has many shades of gr and darkest squares, SHORT SCALE OF CONTRAST HAS A SMALL NUMBER OF GRAY TONES AND IS THE RESULT OF LOW kVp. A shorter scale of contrast is more ideal to ex- amine bone structures, as shown in Figure 10-10. Radiographs appear black and white, with very little gray tones. The disadvantages of a scale of contra: too short are important. Exposure factor: to produce a short scale of contrast use a low and darkest density values, he change from one step to the next is moreContrast scale Long scale—Low contrast Low degree of contrast Not enough contrast High kVp image Increased exposure latitude FIGURE 1-9. The element ofthe long scale of contrast Kilovoltage selection. Radiographs of the spine, skull, and other more dense anatomic structures may produce images with the thickest areas under- penetrated. Lower kilovoltage selections needed to produce a short scale of contrast may be inadequate for penetrating thicker body parts. Close examina- tion reveals a silhouette without visualization of structural detail (Fig. 10-11). The areas where inadequate penetration by the x-ray photons exists are clear (white) because no exposure reached the film, resulting in an absence of black metallic silver deposits. There is no image recorded on the film without adequate penetration of the part. Frequently, radiographs with a short seale of contrast exhibit significant clear areas where penetration did not occur. A scale of contrast that is too short may have limited diagnostic value although it looks pleasing to the human eye. Another point to remember with short scale of contrast is that because lower kVp selections are used, the amount of radiation absorbed by the pa- tient increases. The terms associated with short scale of contrast RADIOGRAPHIC CONTRAST 105, are higher contrast, high degree of contrast, and more contrast (Fig. 10-12), High contrast or high degree of contrast refers to the abrupt and pronounced borders that are present There is no gradual change with small difference in density; the changes in adjacent densities are abrupt. The phrase “more contrast” refers to the appearance of mostly black and white or clear areas. Ifa densitometer was used to measure each density level present, the number of readings would be less than with a long scale of contrast. The lower kVp exposures for short scale have less exposure lati- tude. The margin of error is small for producing a good radiograph. Radiographic contrast is an extremely complex factor as radiographers attempt to consistently achieve high-quality radiographs. The selection of factors is extremely important. Kilovoltage is the factor that controls contrast. High kVp produces long-seale and low kVp produces short-scale con- trast. To review the facts associated with kVp, radiographers must understand that high kVp pro- duces more scatter; however, the amount of scatter radiation absorbed by the patient is less. KILOVOLTAGE CONTROLS CONTRAST. With low kVp, less scatter is produced and the radiograph does not have many gray tones; however, the amount of radiation absorbed by the patient is increased. To compromise with the scale of contrast, radiog- raphers must try to produce radiographs with a moderate scale. A moderate scale of contrast is “in between” a long and short scale, as demonstrated in Figure 10-13. The kVp selection is made to achieve optimal penetration of the part. This is called optimal kVp selection. The kVp selection is neither very low nor very high. Optimal kVp will assure that the finished radiograph demonstrates structural detail without the excessive gray tones of long scale (Fig. 10-14). FACTORS THAT AFFECT RADIOGRAPHIC CONTRAST Film-Screen Systems Film-screen systems must be selected with the desired characteristic of contrast in mind. In gen- eral, the use of screens will incre106 RADIOGRAPHIC IMAGING. cae and short scale of cont Radiograph nting long. scale of y litle c the soft issue and skeleton jozraph with short ‘Oa black and white appearance, and there isa pronounced difference between the skeletoFIGURE 10-11. Radiograph ofthe skull demonstrating undespenetra tion of the par faster the screen, the greater the contrast or the shorter the scale. This is most evident in the use of calcium tungstate screens with regular-speed x-ray film, In general, slow screens produce the longest scale or lower contrast, and high-speed screens pro- duce the shortest scale, with more contrast. Images, with moderate scale of contrast tend to provide more ignostic information; therefore, the selection of the film-screen system is very important. IN GENERAL, AS INTENSIFYING SCREENS. INCREASE IN SPEED, CONTRAST INCREASES. The use of rare earth phosphors has produced new technology in the film-screen selection proct Studies have shown that rare earth phosphors work best at approximately 70 to 80 kVp. This kVp range provides optimal kVp for a moderate contrast scale. In addition, the speed of rare earth provides the advantage of a slightly shorter scale of contrast. RARE EARTH SCREENS PRODUCE RADIOGRAPHS WITH A SLIGHT INCREASE IN CONTRAST OVER CALCIUM TUNGSTATE SCREENS. RADIOGRAPHIC CONTRAST 107 The objectives in the selection of a film-screen system should be: acceptable speed, good contrast (moderate scale), and the ability to adequately vis ualize the structural details of the anatomic areas of interest. Processing, The proper time-temperature relationship and chemical mixtures are necessary to build proper contrast during the processing cycle. Chemical fog will tend to prevent good contrast. Fog may result if temperatures are too high. If the temperatures are too low, the density will not be sufficient to build adequate contrast on the film. Underdevelop- ment prevents the film from building adequate contrast Contrast Scale Short scale — High contrast High degree of contrast More contrast Low kVp exposure Decreased exposure latitude 50 FIGURE 10-12, Kv108 RADIOGRAPHIC IMAGING FIGURE 10-13. Radiographs of the chest exhibiting diferent scales of contrast. A, A shorts contrast B, A very long scale with many say tones. C, A more moderate scale of contrast. FIGURE 10-14. High-quality radiographs with g a moderate scale of contast, 8B, A radiograph of the abdomen representing a longerPROCESSING MUST BE OPTIMAL TO. PRODUCE ADEQUATE CONTRAST. Beam Restriction The use of beam restriction is very important in the recording of good contrast. As the beam becomes, more restricted to the actual size of the part, less, scatter radiation is produced, which in turn reduces, fog, resulting in greater contrast on the film. Scatter hinders the production of radiographs with good contrast. The use of beam restriction will increase contrast and produce radiographs with a shorter scale of contrast. BEAM RESTRICTION PRODUCES AN INCREASE IN CONTRAST. Grids Grids are devices located between the patient and the film. When a grid is in place, it absorbs scattered x-rays that travel in many directions to prevent hitting the film. Seatter rays that travel nearly parallel with the remnant primary x-ray photons exiting the body will not be absorbed by the grid. ‘The use of grids will require an increase in exposure factors; however, there will be an increase in the contrast, and the result will be a radiograph with a shorter scale of contrast. RADIOGRAPHIC CONTRAST 109. TABLE 10-1. FACTORS THAT AFFECT CONTRAST Controlling Factor Tafluencing Factor ovollage kVp) Tissue composition Contrast media Pathology Fos Seatter radiation Film-screen systems Processing Beam restriction Gud THE USE OF GRIDS PRODUCES AN INCREASE IN CONTRAST. Pathology and Composition of the Part The composition of the anatomic part of interest is important in understanding the characteristics of contrast as recorded on the film. Disease processes that increase water content will result in radio- graphs exhibiting longer scale. The same is true for ® fat content, Obese patients with increased fat con- tent will exhibit radiographs with longer scale. On the other hand, disease processes that cause tissue destruction such as osteoporosis will generally ex- hibit a short scale of contrast. The same is true for tissue filled with air or gas shadows—the recorded contrast is greater. Contrast on a radiograph can be enhanced by the use of compression. Abdominal tissue can be compressed by exposing the patient using the posterior-anterior projection instead of the anterior-posterior projection. Table 10-1 reviews contrast and the factors that control and influence contrast.Radiographic Definition and Distortion CHAPTER 11 CHAPTER OBJECTIVES 1 2 3 4 5 6. 18. Define the term ‘maximum definition. Define umbra and penumbra Describe the relationship of penumbra and unsharpness. Explain the umbrella concept for image definition, List the factors associated with image definition. Define or describe: Recorded detail Visibility of detail Distortion List the geometric factors associated with recorded detail Explain how each of the geometric factors (OFD, FFD, and FSS) affects image unsharpness. Describe how motion interferes with image distortion. List examples for reducing unsharpness with the geometric factors and motion. Define quantum mottle. . Describe the conditions that produce mottle. . Explain the effects on image resolution by the thickness of the phosphor layer and the conversion efficiency of the phosphor . Describe the bar test used to evaluate the resolving power of the imaging system: . Explain how screen-film contact affects image definition. Define image distortion Differentiate between foreshortening and elongation Identify the factors that cause size and shape distortion Define the term “visibility of detail,” Define magnification factor and write the formula. Differentiate between overexposure and underexposure, and list the causes, Describe how fog and scatter affect visibility of detail Explain how kVp and mAs can affect visibility of detail WWKEY WORDS AND TERMS Definition Sharpness of the image Maximum definition Umbra Penumbra Unsharpness Visibility of detail Focal spot size (FSS) Focal-film distance (FFD) ‘Object-film distance (OFD) Geometric factor Voluntary motion Involuntary motion Blurring of image Restraints Immobilization of part ‘Compression bands Sand bags Screen mottle Quantum mottle Screen “‘noise’’ Phosphor layer Phosphor conversion efficiency Image resolution Bar-test pattern Line pair/mm Screen-film contact Distortion Size distortion Magnification Shape distortion Elongation Foreshortening Magnification factor Overexposure Underexposure RECOMMENDATIONS FOR GENERAL DISCUSSION QUESTIONS puauna 112 Discuss each factor related to definition (umbrella). Describe the difference in recorded detail and visibility of detail. What are the requirements to achieve good recorded detail? What are the requirements for assuring the best visibility of detail? What should be included in a procedure guide for producing well-defined radiographs? What steps should be taken to eliminate or reduce distortion of the image?RADIOGRAPHIC DEFINITION AND DISTORTION DEFINITION Radiographic definition describes the clarity and sharpness of the image. The term “definition” means to make definite, clear, and refers to the sharpness of outlines and the detail or sharpness of minute markings. DEFINITION DESCRIBES THE CLARITY AND SHARPNESS OF THE IMAGE. ‘Maximum definition in radiography describes an image that outlines objects extremely well. The lines and markings of the actual anatomic part are the best possible. Maximum definition implies that, a radiograph shows minimum magnification and. distortion and has clarity that enhances the visibil- ity of the anatomic markings. There are inherent limitations in radiography that prevent the production of a perfect radiograph. For example, the anatomic part of interest is inside the body and therefore cannot be placed next to the film. This causes the part to be recorded larger than, its actual size. In addition, there is no specific point. source for the production of x-rays. Photons that originate from different points on the target area cause some unsharpness as they traverse the bor- ders of objects. This results in slight blurring of the object. In radiography, the true object recorded on the film is called the umbra and the small or thin area of blurring around the umbra is called the penumbra (Fig. 11-1), UMBRA IS THE TRUE OBJECT RECORDED ON THE FILM. PENUMBRA IS THE THIN BLURRED, AREA AROUND THE UMBRA. Penumbra is also known as unsharpness. Pen- umbra places a limitation on radiographic defini- tion. Figure 11-2A shows unsharpness around the edge of the image with a wide beam, whereas Figure 11-2B shows less unsharpness with a narrow beam. Radiographers cannot completely eliminate pen- umbra or unsharpness; however, it can be mini- mized so that image quality is not compromised. PENUMBRA IS UNSHARPNESS. 113 Primary beam Penumbra _ (unsharpness) —4 \ i the doject FIGURE 11-1. The true image of the object recorded on the film is the umbra. The bluring around the edge ofthe umbra isthe penumbra ‘or unsharpness, Factors must be combined in such a way that an image with the best possible sharpness and detail is produced. Good definition is present with minute ines and details visible, and it enables the radiol- ogist to evaluate for abnormalities. Figure 11-3 shows a radiograph with good definition. In radiography, definition is an all-encompassing term that includes all of the visible characteristics of a radiograph (Fig. 11-4) As indicated in the diagram in Figure 11-4, definition is a comprehensive term. It includes all factors used to produce a radiograph that will di- rectly affect the image detail and sharpness, as well as all factors that affect the visibility of detail. Those characteristics associated with definition are recorded detail, distortion, and visibility of de- tail. Radiographers use these factors to produce and evaluate radiographs. THE CHARACTERISTICS OF DEFINITION ARE RECORDED DETAIL, DISTORTION, AND VISIBILITY OF DETAIL. Recorded Detail Recorded detail is the actual or visible detail of the part of interest recorded on the film. Recording114 RADIOGRAPHIC IMAGING wv w (a) (8) FIGURE 11-2. A wide-angle tnsharpness(U) or pen imary beam (A) will result in moe the image detail is dependent on the focal spot size (FSS), the distance between the focal spot and the x-ray film (focal-film distance [FFD), the distance between the part of interest and the film (object-to- film distance [OFD)), absence of object movement, and the type of recording system used to produce the image. FSS, OFD, and FFD are significant factors that control unsharpness by their geometric FIGURE 11-3. Radiograph that exhibits good definition, The skeletal vkings are visible with good differentiation between bone and soft tissue. The borders of the bones and soft tissue are very distinct Recorded detail s adequate of deta is very DEFINITION Recorded detail Visibility of deta tortion FIGURE 11-4. Radiographic definition is a comprehensive term that includes all factors that are used to produce a radiograph, All factors are related to recorded detail, distortion, ancl visbity of detail nature in the production of x-rays. F' FFD are called the “geometric factors, $8, OFD, and THE GEOMETRIC FACTORS IN RECORDING DETAIL ARE FFD, OFD, AND FSS. Focal Spot Size Figure 11-5 i an enhanced diagram that dem- tes how the use of a large focal spot will increase unsharpness on the image. Large focal spot — small focal spot wo YW) w) FIGURE 11-5. The use of a large focal spot will result in increased blurring (ansharpness (Ul) around the abject. The unsharpness i caused by scrays that originate fram cliferent points an the focal spot Striking the edge ofthe object.RADIOGRAPHIC DEFINITION AND DISTORTION The illustration demonstrates how the use of a large FSS results in increased image unsharpness, ‘The unsharpness is caused by x-rays originating from different points on the focal spot. As they travel tangentially across the edge of the anatomic part of interest, the outer edge of the object receives xray photons from all areas of the focal spot to help record the image on the film. The effect produces a fuzzy, unsharp border around the area of the object. ‘The human eye reads this as unsharpness. As unsharpness increases, the outlines of the objects become more difficult to identify. Increased un- sharpness on a radiograph interferes with the ra- diologist’s ability to evaluate the structures. THE SMALLER THE FOCAL SPOT SIZE, THE GREATER THE IMAGE SHARPNESS. Atthe time of the selection of the exposure factors, care must be taken to select the smallest possible focal spot that is practical. This will result in the best possible image sharpness. Caution must be exercised. The radiographer should consult rating charts to determine if the selection of the FSS and technical factors are compatible with that specific x-ray tube. Focal-Film Distance Distance between the focal spot and the x-ray film will affect sharpness. Figure 11-6 demon- strates how changes in the FFD will affect unsharp- ness. The illustration shows that unsharpness in- creases as the FFD is decreased. The illustration demonstrates the concept that x-rays originate from the entire surface of the focal spot and not from a single point source. Photons that originate from these different points pass tan- gentially across the edge of the object and record information in a slightly different area. The result is unsharpness. As the FFD decreases, the unsharp- ness will increase. THE LONGER THE FFD, THE GREATER THE SHARPNESS OF THE IMAGE. _ Radiographers must utilize the longest FFD that is practical to minimize unsharpness. In most radi- ology departments, examinations are performed 115 3 oes 0) Y» wv wy) (A) Ad (8) Unsharpness FIGURE 11-6. As the foca-film distance (FFD) increases, unsharpness ofthe image will decrease with a standard FFD. It is important to follow the standard guide and to refrain from making arbi- trary changes in the FFD. Object-Film Distance One of the first principles to be learned when positioning a body part to be imaged is to place the anatomic part of interest as near the film as possi ble. This principle is very important in radiographs The primary reason for placing the part as near the film as possible is to produce maximum recorded detail. The OFD is a factor in size distortion, As the OFD increases, so does the image unsharpness and size distortion (magnification). THE SHORTER THE OFD, THE GREATER THE IMAGE SHARPNESS. ‘The distance from the part of interest and the film is the third geometric factor for evaluating recorded detail. Figure 11-7 illustrates how changes in the OFD will contribute to unsharpness. As the distance between the object and the film increases, so will the unsharpness. The concept is116 — RADIOGRAPHIC IMAGING oy loro o © wu Unsharpness FIGURE 11-7. increase unsharpness An increase in the object‘ilm distance (OFD) will the same as described for FFD and OFD. The pho- tons originate from different points on the target and result in a slight difference in recording the image on the film It is important always to place the part as near the film as possible. Inasmuch as the part cannot be placed directly next to the film, the geometry of the illustrations indicates some unsharpness will always be present. Geometric unsharpness as produced by the FFD, FSS, and OFD can be minimized by a long FFD, small FSS, and a short OFD. Motion The biggest enemy in the production of a good radiograph is motion. No matter how well the job is done with the selection of the technical and geometric factors, if the part moves during the exposure, detail can not be accurately recorded. The result is a blurred image that is useless to the radiographer and radiologist. The examination must be repeated. Motion must be eliminated in general radiography (Fig. 11-8) To better understand how to eliminate motion, one must first understand the characteristics of motion. Motion that is voluntary is easiest for ra- diographers to control. Movement of the extremities, body movement, and breathing are considered to be voluntary. This means that instructions must be given by the radiographer and understood by the patient so that movement does not occur at the time of the exposure. MOTION OF THE PART MUST BE ELIMINATED DURING THE EXPOSURE Patients are often anxious and apprehensive at the time a radiograph is produced, and movement may occur even if the patient understood the in- structions. Minimum restraints that will provide security to the patient, such as sand bags across an extremity, can help reduce the possibility of motion. Involuntary motion is present in the gastrointes- tinal tract, cardiovascular system, and with patients who may be incoherent or unconscious and cannot hold their breath for the short time period needed to make a radiographic exposure. Involuntary mo- on presents a real challenge to the radiographer. Suggestions for controlling involuntary motion at the time of the exposure would be to use the shortest possible exposure time as well as immobilization through the use of compression bands, sand bags, ete, Special pediatric restraints are available for radiography of small children and babies. FIGURE 11-8. Motion can be a major problem in producing radiox 'staphs with good definition. A, A radiograph with the part in motion 1 the time of the exposure Overall bluring of the image has prevented the recording of good image detail. 8, A "improved image detail in the absence of motion of the pat.RADIOGRAPHIC DEFINITION AND DISTORTION Recording System (Film-Screen Combinations) ‘The imaging system composed of the screen-film combination will also control and influence the recording of detail. Film graininess, screen struc- ture, and screen mottle or quantum mottle (noise) must be considered in the evaluation of screen-film effectiveness in recording detail. Film graininess is another factor; however, it is not a major factor in diagnostic radiology. Film graininess refers to the inherent uneven distribu- tion of silver crystals in the film emulsion. Film graininess would be a factor if radiographs are enlarged for viewing. Screen structural defects may be present in the manufacturing process, producing imperfections in, the phosphor layer. Neither of these factors is of great significance in general radiography. Screen mottle or quantum mottle (noise) is the fluctuation in the number of photons absorbed by the sereen phosphors. The x-ray beam is made up of different energies. The multiple energies in the primary beam, along with the fluctuation in the photon absorption by the screen, result in non- uniform light exposures to the film. Mottle looks like a “snowy” television screen and prevents the’ recording of good detail.’ Quantum mottle is more evident in high-speed systems, An exception would be with screens where the layer of phosphors has been increased in thick- ness to produce faster speed. In the manufacture of screens using new technology, a more efficient phos- phor rather than increased thickness of the phos- phor layer is used to produce speed. The fast screens with a thicker phosphor layer will absorb more photons and require the mAs to be reduced. The increased thickness of the phosphor layer produces more light diffusion, which obscures the mottle. However, the increased diffusion of light will increase unsharpness of the image, as shown in Figure 11-9. Rare earth systems, on the other hand, are more efficient and do not produce as much light diffusion and unsharpness. The increased ef- Film KAN OSI YZ WYN if Screen phosphor layer Thick layer FIGURE 11-9. A thicker phosphor layer produces greater light diffusion. As the amount of ligt diffusion increases, u 117 ficiency of the rare earth phosphors does not require a thicker layer to achieve an increase in speed. Therefore, with rare earth screens, the diffusion of light that reduces image definition is not a factor in image production. INTENSIFYING SCREENS WITH MINIMAL LIGHT DIFFUSION WILL PRODUCE BETTER RECORDED DETAIL. Quantum mottle is easier to recognize as the film speed and sereen speed increase. The milliampere- seconds (mAs) is reduced and the patient receives less radiation; however, fewer photons will be avail- able to produce the image. With fewer photons available, a non-uniform pattern of light strikes the film, producing an increase in quantum mottle. Quantum mottle is most significant with high kilo- voltage peak (kVp) and low mAs exposure used with fast imaging systems. Quantum mottle will obscure recorded detail, WITH FAST IMAGING SYSTEMS, MOTTLE IS A. PROBLEM WITH EXPOSURES USING HIGH kVp. AND LOW mAs; MOTTLE WILL OBSCURE RECORDED DETAIL. a. |. The ability of an imaging system to provide good image resolution can be measured using a leaded bar-test pattern (Fig. 11-10). The test pattern is sectioned with bars of lines, with interspacing in a specific pattern, The test pattern is radiographed. The film is processed and viewed by the radiographer to Film Screen Phosphor Tayer Thin layer sharpness will decrease118 RADIOGRAPHIC IMAGING A B FIGURE 11-10. Image resolution can be tested using a leaded bar test pattern, A, The bar test pattern is held in front of a viewbox, and the pattern of bars is visible. A radiograph made using the test patter determine the number of line pairs that can be — Screen-Film Contact visualized ‘A line pair is one line (bar) and one interspace For example, if eight line pairs are visible, this means that eight bars and eight interspaces are visible, and the system has a resolution value of 8 line pairsimm. The higher the number of line pairs/mm that are visible, the greater the resolving power of the imaging system and its ability to record THE GREATER THE RESOLVING POWER OF THE IMAGING SYSTEM, THE GREATER THE RECORDED DETAIL. How many line pairsimm can be visualized? The answer is dependent on the observer. A particular sereen-film system with the ability to produce good detail may demonstrate 8 to 10 line pairsimm. Table 11-1 compares sample screen systems. TABLE 11-1. SCREEN SPEED AND RESOLUTION Screen Type Speed Tine Pairs MM Gale targa Slow (50) 5 Calum tungstat Fast (200 57 Calcium tungstate ‘Medium (100), Rare earth 400 Rare earth 200 c Screen-film contact is the pressure exerted by the film holder as it encloses the x-ray film. The pres- sure should be evenly distributed across the surface of the film. Screen-film contact is essential to record detail accurately. Poor screen-film contact reduces sharpness of the image. Sereen-film contact can be evaluated by the radiographer, as described in Chapter 5. A wire mesh is imaged using the film holder suspected of poor screen contact. The result would show area(s) of increased or decreased density representing poor contact and decreased sharpness (Fig. 11-11), GOOD FILM-SCREEN CONTACT MUST BE PRESENT TO ACHIEVE MAXIMUM DETAIL. DISTORTION The misrepresentation of size and/or shape of the object is called distortion. In almost every radio- graph there is distortion of the part in the form of size distortion (magnification). Magnification of the part oceurs because the part is never in direct, contact with the film. It would be best to have a zero OFD, but it is not realistic in medical radiog- raphy. Radiographs are usually made with 2 to 10 inches between the part and the film.RADIOGRAPHIC DEFINITION AND DISTORTION 119 Light fog Area of blurring A 8 FIGURE 1111. Filmscreen contact is important in producing a radiograph with good definition. A, A radiograph representing atest for scree film contact. Because the overall density and image detail is very good, the screen-film contact adequate. B, A radiograph with povr fils screen contact, especially on the upper edge. The screens do not come together, and light entered the casseite to expose the film, fhe imawe Of the wire mesh is also blurted near the fogged area DISTORTION IS THE MISREPRESENTATION OF THE SIZE AND/OR SHAPE OF THE PART BEING RADIOGRAPHED. There are two types of distortion: size distortion (magnification) and shape distortion (true) (Fig. 11-12), Size distortion or magnification occurs whenever DISTORTION oa Te Size (Magnification) Shape (True FIGURE 11-12. the two types of distortion —size shape (true the OFD is greater than zero. The greater the OFD, the greater the magnification. The thickness of the part will affect the OFD. For a lateral projection of the lumbar spine, a slightly obese patient will produce a significantly longer OFD, whereas a thin patient would allow for a shorter OFD. Patient thickness and part thickness are factors that cannot. be changed. Skill must be used to place the part as, near the film as possible. Magnification distortion is demonstrated in Figure 11-13. MAGNIFICATION CAN BE REDUCED WITH A SHORT OFD. —— Radiologists are accustomed to viewing radio- graphs with specific amounts of magnification. How- ever, when tumors or other abnormalities are pres- ent, it may be important to know the approximate120 RADIOGRAPHIC IMAGING oro) Object Jor FIGURE 1113. As OFD increases, the amount of magnification will inerease. To reduce magnification, place the object as near the film 3s posible. amount of magnification. This can be calculated using the formula to determine the magnification factor. Magnification factor FFD Niet FFD ~ OFD EXAMPLE: ‘What is the magnification factor for an object that is located 4” from the film with a 40” FFD? 40 we 40-4 40 M=-—— 36 M= 11 ‘The example indicates that an object imaged with a 40-inch FFD and a 4-inch OFD will have a magnification factor of 1.1. The factor indicates the amount of magnification of the object. The example shown is magnified by a factor of 1.1. If the actual size of the object is 2.5 em, the image will be 2.5 x 1.1 or 2.8 em on the finished radiograph. Shape distortion or true distortion is present when the image does not represent the true shape of the actual object. As indicated earlier, size distortion is almost always present; however, shape distortion is not. When the shape of the object is distorted, it is described as elongated or foreshortened. Elongation refers to an image that is “stretched” and appears longer than the actual size. The stretching of the image is produced when the x-ray tube or film holder is improperly aligned, with an excessive angle (Fig. 11-14), ELONGATION AND FORESHORTENING ARE THE RESULT OF IMPROPERLY ALIGNED TUBE, FILM, AND PART. Foreshortening occurs when the object appears shorter than its actual size; it results from poor alignment of the part and the film. Radiographs should be produced with a minimum of foreshort- ening and elongation (Table 11-2). ‘The four rules listed in Table 11-2 are necessary for practicing radiography. For special views of certain anatomic parts, such as small joints or articulations, tube angle or part rotation may be necessary for adequate visualization of the part. For example, in radiography of the cervical vertebrae, a 45° angle of the body part is required to demon- strate the intervertebral foramina. VISIBILITY OF DETAIL A vacationer driving over the Golden Gate Bridge into San Francisco on a clear day can see the lovely city by the bay in all of its beauty. But from time to time, the vacationer may only see a thick layer of fog. The fog has obscured the view of the city. Is the city there? Yes; however, the fog has prevented visibility of the city. The analogy can be used to describe visibility of detail in radiography. Fog from scatter radiation is a detriment to the visibility of detail. VISIBILITY OF DETAIL IS THE ABILITY TO SEE DETAIL RECORDED ON THE FILM _ TABLE 11-2. ACTIONS TO REDUCE DISTORTION The radiographer should 1. use the longest acceptable FFD. 2. place the part as near the film as possible: short OFD. 3. place the object of interest as near parallel tothe film as possible, 4, Use a perpendicular central rayinane] ioe Foreshortening Elongat a) (8) FIGURE 11-14. tening occur ih an excessive angle. The scapula is used to e on. C, A scapula with minimum distortion allel tothe film a5 of the scap ced with an extreme tube angle. The im Broduced with th122 RADIOGRAPHIC IMAGING FIGURE 11-15. Radiographs that have been overex much density to adequately the pars of interest. B, A to produce adequate contrast and make detail visib Overexposure and Underexposure In order for visibility of the image to be at its best, proper density is critical. Density must be sufficient to exhibit good contrast of the various tissues. Too much density or too little density is a result of overexposure or underexposure (Fig. 11-15), VISIBILITY OF DETAIL DEPENDS ON THE PRESENCE OF SUFFICIENT DENSITY AND. CONTRAST. ‘A radiograph that is overexposed has too much density. The blackening on the film is so great that nsity. There i not enough blackening on the film it obscures the detail of the image. This is the result. of too much radiation exposing the film or possibly a result of fog from seatter or processing chemicals. A radiograph that is underexposed is one that does not have adequate density. The amount of blackening is not great enough to exhibit contrast. sufficient to see image detail TABLE 11-3. QUALITY CHARACTERISTICS AND RELATED ECHNICAL FACTORS, (Quality Character Technical Factor Dera Miliampere (mA) Time |S) kilove r DistaRADIOGRAPHIC DEFINITION AND DISTORTION Density, in the proper amounts, must be present on the radiograph in order to have contrast. Con- trast is important to make detail visible. Without proper density, anatomic details will not be visible, even though they have been recorded on the film. All factors that influence density and contrast will also affect the visibility of detail. Scatter radia- tion will reduce visibility of detail. The selection of ‘accessories must be such that scattered x-rays are absorbed or reduced to prevent fog on the film. Accessories, such as collimators and grids, are im. portant in achieving the best visibility of detail SCATTER RADIATION MUST BE REDUCED TO PROVIDE MAXIMUM VISIBILITY OF DETAIL Penetration of the part is essential to produce good visibility of detail. Kilovoltage must be ad- justed high enough to penetrate the part but not so high as to produce increased scatter radiation. In summary, all factors related to contrast, den- sity, and scatter radiation are important and must. be properly controlled for the best possible visibility. of the detail on the radiograph. Table 11-3 sum- marizes the technical and quality factors. Table 11-4 provides a good overview of how technical and quality factors are inter-related. 123 TABLE 11-4. RADIOGRAPHIC QUALITY Qual Characteristic Controlling Factor Density mAs ip Tissve thickness Tissue density Foreign bodies Contrast media Distance (F#D) Scatter radiation Anode heel effect Processing Equipment ‘operation Filmscreen systems Filters Grids Beam restriction Fos Influencing Factor Contrast bp Tissue composition Contrast media, Pathology Fos Scatter radiation Filmscreen systems Processing Beam restriction Grids Density factors Contrast factors Definition Focal spot size Objects distance Distortion Alignment of Part Film Tube