Medical Imaging

& Applications
X-Rays And CT, Radiography: Physics, Acquisition, Case study
 Radiography

An X-ray study (a radiograph) is a type of medical imaging (radiology) that

creates pictures of your bones and soft tissues, such as organs.

● Radiography - a single image is recorded for later evaluation.

● X-ray uses a very small dose of ionizing radiation to produce pictures of the
body's internal structures.
● Ionizing radiation - Radiation that has enough energy to break an electron
away from an atom which can potentially cause damage to DNA.
● Fluoroscopy - a continuous X-ray image is displayed on a monitor, allowing for
real-time monitoring of a procedure or passage of a contrast agent ("dye")
through the body.
● Tomography - Many X-ray images are recorded as the detector moves around
the patient's body. A computer reconstructs all the individual images into
cross-sectional images or "slices" of internal organs and tissues.
● Angiography — An x-ray of the blood vessels
Radiography : When can be done?

● Bone conditions — fractures, dislocations, bone infections or arthritis,

osteoporosis and bone density (DEXA)
● Lung conditions — such as pneumonia, collapsed lung and lung cancer
● Congestive heart failure
● Blood vessel problems, such as an aortic aneurysm — a bulge in the aorta
● Cancer, e.g. lung cancer, bone cancer, breast cancer
● Blockages of the bowel
● Tooth decay
● Detection of foreign objects, such as when a child accidentally swallows an
item
● To check the position of wires, leads and tubes after surgical procedures
Radiography : When can be done?
X-rays history
● It was invented by Wilhelm
RÖntgen in Dec 22nd 1895.
● He did so by using a cathode
ray tube and covering it in paper
so as to block the electrons from
escaping.
● The x-rays penetrated the paper
and were detected using a
phosphorous screen.
● The first human x-ray was of
Rontgen’s wife hand .
● X-ray uses wavelengths ranging
from 0.01 to 10 nm, frequency
ranging from 1016 to 1019 Hz and
energy 1keV to 100keV.
Ionizing Radiation Ionize substances indirectly using
secondary electrons generated through
their interaction with the substances.
X-rays : Generation and Projection

Air

Bones

Soft
tissue
Fat
 X-rays : Production

X-rays are produced when highly energetic electrons interact with matter, converting
some of their kinetic energy into electromagnetic radiation.

1. A source of electrons (the cathode, filament); the number of

electrons (as well as the number of produced X-ray photons) is
controlled by the product of the tube current and time (mAs).
2. An evacuated space in which the electron are speed up (glass
envelope).
3. A high positive potential to accelerate the negative electrons which
control the energy of the electrons (as well as the energy of the X-ray
photons) (kV).
4. A target which the electrons strike (the anode).
X-rays : Production
Focal Spot Effect

Actual Focal Spot

(Hypotenuse)

Effective Focal Spot

(Perpendicular)

Cathode (filament) —--> activate free electrons

Anode (plate) —-------> provide high positive voltage
Target —----------> generates x-rays
X-rays : Production Cathode Electrons
X-rays photons of
Anode Material Atom
different energies

X-ray Spectrum (Unfiltered) Atom Nucleus

 X-rays : Production
At the anode, electrons can interact with the atoms of the anode in several ways to produce x-ray photons.
Bremsstrahlung and Characteristic Radiation
● An interaction with electron shells produces
characteristic x-ray photons; interactions with
the atomic nucleus produce Bremsstrahlung
x-ray photons
● Electrons that penetrate the anode material and
pass close to a nucleus are deflected and slowed
down by the attractive force from the nucleus.
● The energy of electrons can release an orbital
electron from a shell say K-shell, leaving a hole.
● This hole can be filled when an electron of higher
energy say L-shell or M-shell fill the hole and emit
photons of very specific energy.
Production: Bremsstrahlung
Nucleus field interaction: Bremsstrahlung
Radiation

● Bremsstrahlung: a german word ie

breaking radiation, continuous spectrum
● The energy loss from this diversion is
released as a photon (Bremsstrahlung
radiation).
● Energy and wavelength of this radiations
are bounded by
● E ≤ Emax = qU
● λ >= λmin = hc/qU
Where q is the electric charge of an electron.
For example if U=100kV then Emax= 100keV
Production: Characteristic Radiation

Inner shell interaction: produces characteristic radiation

● Characteristics radiation: characteristics peaks

superimposed onto the continuous spectrum
● Bombarding electron interacts with inner shell
electron
● A higher shell electron moves into the empty
space.
● This movement to a lower energy state releases
energy in the form of an x-ray photon.
● Energy is the difference between two electron
states
E (K𝜶)= EK - EL E (K𝜷)= EK - EM
 Production: X-ray Spectrum

20 keV 150 keV

X-rays : Patient Interaction

● Photoelectric Diagnostic Value

● Compton Scattering Diagnostic Value
● Pair Production Therapeutic Value
● Photo disintegration Therapeutic Value
● Coherent Scatter No use
X-rays : Interaction with matter
The energy that a tissue absorbs from photon
interactions is referred to as dose (kinetic energy
released in matter).

● Absorption = x-ray disappears

(Photoelectric, Pair production &
Photodisintegration)
● Scattering = partially absorbed, x-ray
emerges from the interaction traveling in a
different direction (sometimes with less
energy)
Absorption + Scattering = Attenuation
● Penetration = the degree to which X-rays
have passed through the body.
X-rays : Interaction with matter
X -ray attenuation is the reduction of the X-ray beam due to absorption and
scattering. The amount of radiation that passes through tissue is given by the
Beer-Lambert law
 X-rays : Linear attenuation constant

LAC, defines as a measure of how much the incident

energy beam (e.g. ultrasound or x-rays) is weakened by
the material it is passing through.

● In soft tissues, the dominant elements (e.g. C, H,

O, and N) have very low K-edges, in the range of a
few keV.

● The elements iodine and barium have K-edges

around 30-40 keV, right in the middle of the x-ray
beam spectrum

● The bone elements (calcium) have K-edges around

4-5 keV, between iodine and muscles.
 Interaction with matter : Photoelectric Effect (PEE)

Energies between
10-130 keV

● Inner-shell ionization
● The photon is not scattered it is totally absorbed
● The e- removed from the atom of matter is called a photoelectron, with an energy level equal to the
difference between the incident photon and the e- binding energy.
Ep=E0-Eb OR
● The photoelectric effect is more likely to occur in absorbers of high atomic number (eg, bone, positive
contrast media)
Interaction with matter : Photoelectric Effect (PEE)
● A relatively low energy (low kVp) x-ray
photon uses all its energy (true
absorption) to eject an inner shell
electron, leaving an orbital vacancy.
● An electron from the shell above drops
down to fill the vacancy and, in doing so,
gives up energy in the form of a
characteristic ray.
● PEE contributes significantly to patient
dose,
● as all the photon energy is absorbed by
the patient (and for the latter reason, is
responsible for the production of
short-scale contrast).
 Interaction with matter : Compton Effect (CE)

𝝺 < 𝝺’
𝝺 = 𝝺’

● The incident x-ray interacts with the outer electron shell on an atom of matter, removing it.
● It not only causes ionization but scatters the incident x-ray causing a reductions in energy and the
change of direction.
● Though the x-ray photon is deflected with somewhat reduced energy (modified scatter), it retains most of
its original energy and exits the body as an energetic scattered photon.
● Since the scattered photon exits the body, it does not pose a radiation hazard to the patient.
● It can, however, contribute to film fog and pose a radiation hazard to personnel
 Interaction with matter : Compton Effect (CE)

Energies
above 30 keV
 Interaction with matter : Rayleigh Effect (RE)

● Incident x-ray interacts with an atom of matter, causing it to become

excited. Immediately the atom releases this excess energy and the
scattered x-ray.
● Occurs with energies below 10 keV.
● No ionization takes place.
● Electrons in shells “vibrate”.
● Small heat is released.
● The photon is scattered in different directions.
● The wavelength is equal to the incident x-ray or equal energy.
● Energy in = Energy out , Only changes is direction.
● Also called: Classical,Coherent or Thompson scattering.
Interaction with matter : Pair Production and PhotoDisintegration

Energies above Energies above

~1 MeV ~10 MeV
Interaction with matter : TOTAL
X-rays : Image Formation
X-rays : Detection & Image Formation

To form an image, X-rays are to be captured

and then converted to image.

● Older screen-film
detectors (Emulsion film
containing Ag substance)
● Image intensifier.
● CCD for digital radiography
● Active matrix flat panel
detectors
X-rays Detection: Scintillators
Substances that emit fluorescence when exposed to
radiation such as X-rays and γ-rays, it is a type of
phosphor.
When radiation collides with this substance, it
absorbs its energy and internal electrons move from
the ground state (stable state) to the excited state
(agitated state)
When this electron returns to the original stable
state, it releases its energy in the form of light
emission, called Scintillation
The incident radiation can be measured
quantitatively by photo-electrically converting /
amplifying the emitted fluorescence with a
photomultiplier tube (PMT)
Some of the Scintillators substance are GSO
(Gadolinium Silicate), CsI (Cesium Iodide) etc
 X-rays Detection: Scintillators
● Photographic film is sensitive for X-ray.
● Only 2% of X-ray photons contributes to image on a Film.
● Low efficiency results in large dose of X-ray so intensifying screen is used.
● Screen contains a heavy chemical element that absorbs most of X-ray photons.
● When an X-ray photon is absorbed the kE of released electron raises many other electron to higher
energy state.
● Returning to original state they produce flash of visible light is called scintillation. These light photons
are scattered all directs so two intensifying screens are used in front and behind. This increases
efficiency to 50% from 2%.
● X-ray intensifying screens consists of scintillation substance that exhibits luminescence ie to emit light
after excitation.
 X-rays Detection: Fluorescence & Phosphorescence
● Fluorescence is prompt emission of light when excited by X-ray and is used in
intensifying screens.

● Initially calcium tungstate (CaWO4) was used

● Now rare earth compounds such as gadolinium oxysulfide (Gd2O2S)

● More recently thallium-doped cesium iodide (CsI : TI)

● Which has excellent absorption and good resolution because of needle-shaped or

pillar-like crystals which limits lateral light diffusion.

● Phosphorescence or afterglow is continuation of light emission after radiation

has stopped. Phosphorescence in screen is undesirable effect because it causes
ghost images.
X-rays Detection: Panel CR/IP Cassettes Image Reader

X-Ray Tube

Flat Panel
Vertical Detector

Patient Bed

Flat Panel Horizontal

Detector

Digital Console
X-rays Derivatives: Fluoroscopy
Real time study of Region of interest using x-ray
imaging or called Dynamic Imaging.
X-rays Derivatives: Fluoroscopy
X-rays: Case Study (https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5)

CXR
X-rays: Case Study (https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5)
Series chest x-rays in an 80-year-old woman with COVID-19 pneumonia.
a Chest x-ray obtained on illness day 5 showed peripheral GGO in the LLZ (score 1).
b Chest x-ray obtained on illness day 7 showed increase extent of the GGO diffusely involving the left lung (score
4).
c Chest x-ray obtained on illness day 11 showed increase extent of the GGO involving the right lung, with
increase extent of consolidation involving the left lung diffusely (Total score 8).
d Chest x-ray obtained on illness day 14 showed development of reticulations in both lungs with increase extent
of involvement of the RUZ. (Total score 8).
e Chest x-ray obtained on illness day 17 showed extensive bilateral consolidations mainly peripherally with
increased reticulations (Total score 8).
f Chest x-ray obtained on illness day 18 showed extensive consolidation involving both lungs diffusely (Total
score 8).
The patient died on illness day 18. (GGO: ground glass opacity. LLZ: left lower zone. RUZ: right upper zone)
X-rays: Case Study (https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5)
X-rays: Case Study (https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5)
Background
➔ The coronaviruses are widely distributed among humans and mammals
➔ Six coronaviruses are identified, four of which cause mild common cold symptoms, and
two strains were responsible for Severe Acute Respiratory Syndrome (SARS)
➔ Common symptoms of COVID-19 include fever, cough, dyspnea, fatigue, and myalgia,
less common symptoms are sputum, hemoptysis, headache, and gastrointestinal
symptoms
➔ Reverse Transcription Polymerase Chain Reaction (RT-PCR) on nasopharyngeal and
throat swabs, with a positive rate of 30–70% for diagnosis
➔ Chest x-ray was found to have limited value in the initial diagnosis of COVID-19 with a
sensitivity of about 69%
➔ Radiological findings on chest imaging includes multifocal and bilateral ground glass
opacities and consolidations with peripheral and basal predominance.
X-rays: Case Study (https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5)
Terminologies
GGO:
hazy gray areas show increased density inside the lungs which could indicate
pneumonia or other respiratory disorders.
Lung Consolidation:
when the air in the small airways of the lungs is replaced with a fluid, solid, or
other material such as pus, blood, water, stomach contents, or cells
Reticulation:
thickening of the interlobular or intralobular septa and appears as several linear
opacities that resemble a mesh
Nodules: Lumps usually >1cm
Effusion: Fluid Build up Edema: Swollen of Tissue due trapped fluid
X-rays: Case Study (https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5)
Study Design
● Data collected included sociodemographic characteristics, presenting
symptoms, past medical history, and RT-PCR and chest radiographic findings.
● Retrospective study of laboratory confirmed COVID-19 patients who were
admitted to the isolation wards in a tertiary teaching hospital between March
15 and April 20, 2020.
● chest x-rays were acquired as a digital radiograph in the anteroposterior
projection
● two radiologists who were blinded to the presence or absence of symptoms
● The score is determined by the involvement of each lung by consolidation or
GGO from 0 to 4 (0 = no involvement; 1 = < 25%; 2 = 25–50%; 3 = 50–75%; 4 =
> 75% involvement). (Radiographic Assessment of Lung Edema (RALE) score proposed by Warren )
X-rays: Case Study (https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5)
Patient Characteristics
X-rays: Case Study (https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5)
X-ray Characteristics
X-rays: Case Study (https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5)
Dataset and Pipeline
● Grand Challenge: AI for Radiology (https://grand-challenge.org/aiforradiology/
● Free full-text archive PubMed (https://pubmed.ncbi.nlm.nih.gov/
● Augmenting the national institutes of health chest radiograph dataset with expert annotations of possible pneumonia
● Hospital-scale chest x-ray database and benchmarks on weakly-supervised classification and localization of common thorax
diseases.
X-rays: Case Study (https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5)
Analysis
X-rays Derivatives: Tomography

Tomography is imaging by sections or sectioning

that uses any kind of penetrating wave.
In many cases, the production of these images is
based on the mathematical procedure
tomographic reconstruction
Most algorithms fall into one of two categories:
filtered back projection (FBP) and iterative
reconstruction (IR)

P: Non-tomographic projection

S1, S2 : Cross section images

(tomographs)
Computed Tomography: Basic Principles

Combines a series of X-ray images taken from different angles around your
body and measure X-ray attenuations by different tissues inside the body.
These series/slices are called tomographic images and contain more
detailed/depth/temporal information than conventional x-rays.
Digital “stacking” used to be done to form a 3D image of the patient that
allows for easier identification and localization of basic structures as well as
possible tumors or abnormalities.
 X-rays Derivatives: Tomography

A voxel is a measurement of volume in a structure that

is to be imaged.
Physical Construction: History & Generations
First generation
Translate-Rotate

1. The x-ray beam is picked-up by a single detector.

2. The x-ray source and detector then move together (translate)
3. The two then rotate together to image a different angle
4. This is repeated until a single slice is scanned
5. The two then move down the patient to start imaging a
different slice

This method took 5 minutes per slice to scan

Physical Construction: History & Generations
Second generation
Translate-Rotate

1. The x-ray beam is picked-up by a row of up to 30 detectors.

2. The x-ray source and detector then move together (translate)
3. The two then rotate together to image a different angle
4. This is repeated until a single slice is scanned
5. The two then move down the patient to start imaging a different slice
in the patient

This method took 5-90 seconds per slice

 Physical Construction: History & Generations
Third generation Fourth generation Fifth generation
Rotate-Rotate Rotate-fixed Fixed-fixed
1. The x-ray beam hits a row of detectors wide enough to image 1. There is a fixed complete ring of detectors 1. There is a fixed complete ring of detectors
the whole slice 2. The x-ray source rotates around to capture a slice
2. The two then rotate together to image a different angle 2. The x-ray source rotates around to capture a slice 3. Both then move down the patient to begin imaging a different slice
3. This is repeated until a single slice is scanned then the array 4. Fifth generation of CT scanner has been developed specifically
is moved to a different slice (axial scanning). Alternatively, the 3. Both then move down the patient to begin imaging a different slice for cardiac tomographic imaging.
detector array is continually moved down the patient as it
rotates (spiral scanning).
This is not commonly used today. This takes about 50 milliseconds to image a single slice
This is the most commonly used method today and takes about 0.3
seconds to image a single slice
Computed Tomography: Image Reconstruction

A sinogram is a graphical representation of

data from computed tomography (CT)
scans. It shows X-ray intensity
A projection is defined as the line integral of some function on the object: measurements as a function of rotation
angle and detector position.

A CT scanner makes two

measurements: the initial intensity of
each X-ray beam I0, the final intensity
S0(E) = X-ray spectrum as the function of E of each beam, I
E = Energy of Photon
μ = Property of tissue material
s = path length across tissue thickness d
x, y = cartesian space
 Computed Tomography: Image Reconstruction

For monochromatic model when E is fixed in X-Ray Spectrum

Rearranging the above:

Tissue attenuation Profiles Sinogram

For a particular angle 𝜽; the

CT projection measure is ��
line integral of LAC of object
along the line path s=(0, d)

Projection function : Sinogram Components

s
Image Reconstruction: how to reconstruct a cross section of an object from several images of
its projections ?
 Radon transform (Projection Operations) : Saviour!

Consider a 2D function f(x,y) describing an object in terms of projection profiles across l and s:

s
Projection function:

Equation of line:

Projection function:
Alternative Representation

Dirac Delta function: and

y
Properties shows with any
f is defined only for (x-ɛ =0; or x=ɛ) s
l
function f :

��
The Radon transform is widely applicable to tomography, the creation of an image from the projection x
data associated with cross-sectional scans of an object.
 Fourier Slice Theorem
relates
1D Fourier Transform of the projection
with
2D Fourier Transform of the original image
Reconstruction from Projections: Fourier Slice Theorem
Object intensity profile for particular 𝜃 across ⟂r
distance t of line L from origin
1. Compute 1D Fourier transform of
parallel Projection p(s,𝜽):

P(𝜽, 𝝎) =

2. Multiply |𝝎| to P(𝝎,𝜽) for filtration

3. Take inverse Fourier transform of

P(𝜽, 𝝎). |𝝎|

Same
Inverse Fourier Transform 4. Integrate or sum-up over all angles

*u and v are 2D frequencies

Reconstruction from Back Projections: Proof!