1. Image Quality and Patient Dose

2. X-ray tube design - basic principles Electrons generated by thermionic emission from a heated filament (cathode) Accelerating voltage (kVp) displaces space charge towards a metal target (anode) X-rays are produced when fast-moving electrons are suddenly stopped by impact on the metal target The kinetic energy is converted into X-rays (~1%) and heat (~99%)

3. The diagnostic X-ray tube

4. Tube Current (mA)/Exposure Factor (mAs) – Double the mA/mAs, double the intensity – Beam quality not affected Tube Voltage (kVp) – Intensity α kVp 2 – Penetrating power increases with kVp – Higher kVp reduces skin dose Filtration (mm Al) Focus-to-skin distance Factors Affecting Patient Dose

5. Filtration

6. Focus-to-skin Distance: The Inverse Square Law For a point source, and in the absence of attenuation, intensity decreases as the inverse of the square of the distance This is a statement of the conservation of energy

7. Image Quality

8. What is ‘image quality’ Image quality describes the overall appearance of the image and its fitness for purpose Remember: There is always a play-off between image quality and patient dose We only need images that are of diagnostic quality (fit for purpose) – not pretty pieces of art! The main factors to consider are: Contrast Spatial resolution Noise

9. Contrast Most medical images presented as shades of grey from black to white (greyscale) Contrast resolution is the ability to distinguish between regions of the image The amount of contrast between tissues is intrinsically linked to their properties and the imaging modality being used Also influenced by the technique and specification of the equipment being used, and how it is displayed Digital imaging techniques allow image processing to be applied to improve the visibility of details

11. Image contrast The final contrast in the image will depend on a number of factors, such as; Subject contrast – an inherent property of the patient being imaged that will depend on the attenuation coefficients of the tissues (or contrast media), the thickness of structures, the nature of any overlapping tissues and the incident X-ray spectrum (kVp, filtration, etc – discussed previously) Detector properties – film and digital detectors each have different implications for the contrast in the final image Scattered radiation – scatter can degrade image contrast if it reaches the detector as it conveys no information about where it came from. Scatter rejection techniques may be used to remove this.

12. Subject contrast

13. Visibility of object structure – requires physical contrast between the object to be imaged and the surrounding tissues The contrast may be based on a difference in densities or atomic number (chemical composition), coupled with the thickness of the particular material through which the radiation has to pass Proportional to object density x object thickness Also remember, higher kVp = less photoelectric absorption = poorer contrast

14. MaterialEffective Atomic Number Z Density g cm -3 Contrast Index Density x thickness = 4 Soft Tissue - Fat - Water - Muscle 7 6 7.4 7.5 1 0.9 1 4cm 4.4cm 4cm Air7.60.001293100cm Bone141.852.1cm Calcium201.55 Tooth2.41.7cm Iodine534.9 Barium563.51.1cm Barium Contrast Media564.25 Lead8211.30.35cm Subject contrast

15. Contrast between bone and muscle is large at low kV, but decreases with increasing kV Contrast between low atomic number soft tissues is low, even at low kV The contrast between air and tissue (similar Z) is large due to the difference in density

16. Balancing Contrast & Patient Dose Penetration, contrast and patient dose depend on the x-ray beam spectrum. The ‘best’ spectrum provides adequate penetration and contrast, whilst keeping the patient dose as low as possible The spectrum produced is dependent upon the target material, inherent and added filtration, and kilo-voltage

17. Low Energy (kV) = Low Penetration = High Contrast = High Patient Dose High Energy (kV) = High Penetration = Low Contrast = Low Patient Dose Optimal Situation = kV that gives adequate contrast for an acceptable patient dose – will vary for the clinical application Balancing Contrast & Patient Dose

18. Contrast and scatter Primary radiation carries the information to be imaged Scatter obscures this as it carries no information about where it came from The amount of scatter (S) may be several times the amount of primary (P) in the same position The ratio S/P depends on thickness of patient For typical PA chest = 4:1 (20% of photons carry useful information) For typical lateral pelvis = 9:1 (10% of photons…)

19. Scatter reduction Scatter and patient dose may be reduced by; Reducing the field area with collimation (reduce volume of tissue generating scatter) Compress the tissue to minimise overlying structures (reduce volume of tissue generating scatter) Scatter may be reduced at the expense of increased patient dose by; Reducing kVp – less forward scatter is produced and is much less penetrating (less scatter produced) Use an anti-scatter grid to remove scatter from the X- ray beam Use an air-gap to reduce the intensity of scatter reaching the detector

20. Anti-scatter grids Series of thin strips of high Z metal (e.g. Pb) sandwiched between low attenuation spacer material (e.g. C fibre) Typically 0.05-0.07 mm wide with 30-80 strips per cm (the line density) X-rays that hit the grid at oblique angles (i.e. not along the path of the primary beam) are absorbed High proportion (but not all) of the primary beam passes straight through to the film The grid ratio is the depth of the channels divided by its width – typically 8:1 Larger grid ratios = smaller angle of acceptance and better rejection of scatter

21. Anti-scatter grids depth width separation

22. Anti-scatter grids Large fields tend to require higher grid ratios (12:1 or 16:1) Grids generally not used for thin parts of the body or children as less scatter is generated (and increase in dose not justified) Contrast improvement factor is defined as contrast with a grid divided by contrast without Typically between 2 and 4

23. Focussed anti-scatter grids

24. Air-gaps If the detector is moved 20-30 cm away from the patient, a significant proportion of the scatter will miss the detector Due to inverse square law, small reduction in primary intensity (hence, increase mAs to compensate) Also results in a magnified image

25. Air-gaps

26. Magnification Magnification is the result of the diverging X-ray beams travelling in straight lines Reduce by using longer focus-to-film distance or shorter object-to-film distance Magnification exploited in some modalities e.g. mammography

27. Spatial Resolution Spatial resolution describes the ability to see fine detail within an image Fine detail is clearer when the contrast is high e.g. microcalcifications May be expressed as the smallest visible detail, but most common descriptor is the highest frequency of lines that can be resolved in a high-contrast bar pattern

28. Noise Noise is a random, usually unwanted, variation in brightness or colour information in a visible image Noise is one of the most important limiting factors to contrast and spatial resolution The most significant source is quantum noise (or mottle) due to the low levels of radiation used to form an image Other sources include film grain and electronic noise in the image receptor

29. Noise Image noise is most apparent in image regions with low signal level, such as shadow regions or underexposed images Noise gives a grainy, mottled, textured or snowy appearance to an image Noise can mask fine detail in a radiograph Noise reduces visibility of parts of a radiographic image Noise is particularly an issue with image details that are already of low contrast

30. Types of noise Several types of noise contribute to the overall image quality, these are: Quantum Noise – from statistical nature of the interactions of the X-ray beam Secondary Quantum Noise – associated with secondary carriers at each conversion stage in image formation e.g. CR, Image Intensifiers, etc Structural Noise – films/screens/intensifier tube screens/digital receptors. Only tends to be important at high doses where all other sources are negligible Electronic Noise – circuit noise, thermal noise, external electrical device signals. Only obvious at low doses

31. 80kV 40mAs 80kV 0.5mAs

32. Striking the right balance Reduced Exposure = Low Patient Dose = Increased Q-Noise = Reduced Image Quality Increased Exposure = High Patient Dose = Reduced Q-Noise = Improved Image Quality Optimal Situation = Exposure high enough to give a diagnostic image with acceptably low quantum noise, whilst maintaining an acceptable patient dose.