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PHYSICAL AND TECHNOLOGICAL BASES OF ROENTGENODIAGNOSTICS. COMPUTED TOMOGRAPHY

Definition of the discipline Today you begin the study of a new discipline, which is termed "radiodiagnostics and radiotherapy". The discipline has two peculiarities. The first is that it studies diagnostics of all illnesses without any exception, being universal. And it means that knowledge of this discipline will be extremely necessary for you whatever brunch of medicine you would work in the future. The second peculiarity feature is that the discipline combines some medical specialities, such as: a radiodiagnostics (radiology), ultrasonic diagnostics, radioisotopic diagnostics and beam therapy. Let's begin the study of the discipline with definition of the concepts "radiodiagnostics" and "radiotherapy". You have known already, that the term diagnostics of diseases means their revealing, and therapy - treatment. The term radial means application of different sort of irradiation for this purpose, which exist in nature. A science, which studies these questions is termed as an radiology from Latin radialis, that means beam. The discipline accordingly consists of two parts: radiodiagnostics (diagnostic radiology) and radiotherapy (therapeutic radiology). In such order we'll study these parts - at first radiodiagnostics, and then radiotherapy. Radiodiagnostics (diagnostic radiology) part of radiology, which studies application of irradiations with the purpose of diagnostics of human diseases. From the course of Latin you know such proverbs: "Diagnosis certa - ullae therapiae fundamentum!" - reliable diagnosis is the basis of treatment. Or another: "Bene dignosctur - bene curatur ", that means: better diagnosed - better treated.

3 Radiodiagnostics posesses a leading role in the revealing of diseases. PHYSICAL PRINCIPLES OF RADIODIAGNOSTICS AND RADIOTHERAPY Irradiations, which are applied in radiodiagnostics and the radiotherapy can be divided into two groups: ionizing and non-ionizing. Ionizing termed the irradiations, which cause activation and ionization of atoms, transiting through the medium. The nonionizing radiations do not cause such effect. According to the physical properties the ionizing irradiations are divided on photon or quantum and corpuscular. The photon or quantum ionizing irradiations represent a stream of electromagnetic waves. X-ray and gamma radiation belong to them. The corpuscular ionizing irradiations represent a stream of positive or negative charged or neutral elementary particles. The alpha-particles, beta-particles (electrons and positrons), protons, neutrons, mesons and some other elementary particles belong to them. Properties of ionizing irradiations: 1. 2. 3. 4. 5. Ionizing activity Penetrating activity Fluorescent activity Photochemical activity Biological activity

The non-ionizing irradiations, which are of a wave nature too (slide 1), are applied only in radiodiagnostics (radiotherapy studies only ionizing radiations). Radiowaves which underlie magnetoresonant diagnostics and infrared waves, which underlie thermo diagnostics belong to them. They also represent a stream of electromagnetic oscillations (waves).

4 Conditionally the ultrasonic waves are included in the group of non-ionizing radiations, which represent a stream of mechanical, sound oscillations. Thus, modern radiodiagnostics studies five methods: 1) 2) 3) 4) 5) magnetoresonant; thermographic; ultrasonic; roentgenological; radioisotopic

The roentgenological and radioisotopic methods belong to ionizing, others - to non-ionizing methods of radiodiagnostics. PHYSICAL AND TECHNOLOGICAL BASES OF ROENTGENODIAGNOSTIC. Source of irradiation. structure of roentgenodiagnostic instrumentation The source of radiation of Roentgen rays is the X-ray tube. It represents the glass cylinder with created vacuum and two electrodes - cathode and anode are disposed. The mechanism of formation of Roentgen rays On the cathode through the reducing transformer the alternating current by a voltage 12 V moves which heat ups a filament (like, as in an electrical bulb). Due to warming, around of the filament so-called "electronic cloud" is formed. Further, through the system of rectifiers (kenotron) from the high-voltage generator on the tube a direct current by voltage 10-150 V is passed. Thus the directional movement (emission) of electrons from the cathode to the anode begins. At interaction of electrons with the anode atoms is gained deceleration and characteristic X-ray radiations. The process of the formation of Roentgen rays is controllable. The penetrating ability of Roentgen rays directly proportional to the enclosed voltage. The roentgenodiagnostic unit, which is the electrophysical generator, consists of the X-ray tube placed in a protective metal housing and anchored in the holder, high-

5 voltage generator with the system of rectifiers, table for positioning of the patient, operating board and receiving device. Object of examination. Artificial contrast study of the object. Object of a X-ray examination is the man (patient). At equal thickness of tissues stratums, the radiation is most of all absorbed by an osteal tissue. Twice less it is hold by parenchymatous organs, muscles, fluid mediums of the organism. The most less it is absorbed by a fatty tissue, and gases - air in lungs and stomach, gas in intestine. The more radial absorption by explored body, the more intensive shadow on the receiving device. Nevertheless, a series of organs has poor natural contrast range and with the purpose to improve it, an artificial contrast study is applied. Substances, which are used for the contrast study of organs and systems are termed X-ray contrast substances. The X-ray contrast substance are divided into two groups: roentgenpositive and roentgennegative. Roentgenpositive substances have a high relative density, well absorb Roentgen rays and give on the receiving device the intensive shadow image. They, as a rule, created on the basis of heavy elements: Barium or Iodum. For example: aqueous suspension of the Barii sulfas - for the examination of gastrointestinal tracts; iodic solutions of organic compounds - for examination of the vessels, liver, kidneys and cavities of heart; iodinated oils - for examination of bronchi, lymphatic vessels, cavity of the uterus, fistulas. Roentgennegative substances very little absorb Roentgen rays and on the receiving device give an enlightenment. It is gases, for example: a carbon dioxide - for administration in the blood; nitrous oxide - in the cavities of the body and fat; Oxygenium - in pleural and abdominal cavities; air - in the digestive channel. There are two methods of the contrast study of organs: the first is direct, mechanical introduction of the contrast substance (esophagus, stomach, intestine, biliary and urinary tracts, cavity of the uterus, bronchi, lymphatic and blood vessels). Second is

6 based on the ability of some organs to absorb from the blood flow contrast substances, injected into the organism, to concentrate and to discharge them. Technology of formation of the X-ray image. The technology of formation of the X-ray image includes three components: a source of irradiation, object of examination and receiving device, on which the visual shadow image of explored site appears. The Roentgen rays, passing through the body of the patient get on the one of receiving devices: X-ray film, semiconductor selenium plates, fluorescent screen, electronnooptical transformer and dissymmetric detectors. Methods of X-ray examination According to receiving of the image, the methods of X-ray examination are divided into three groups: ) for general assignment (universal, basic) - table 1; b) additional - table 2; c) special - table 3. Such division is conditional, however, it is standard in the medical literature. It is necessary to note, that with the appearance of computer technologies, other division has formed, in which the technological level of receiving of the diagnostic information exists. According to this division, also three groups of methods are distinguished: ) the traditional or conventional (standard) technologies, last term is more common abroad and at international scientific forums meets rather frequently; b) computer technologies; c) intervention technologies.

7 Table 1 Methods of X-ray examination of general assignment (universal, basic) Name of the receiving device 1 X-ray film Name of procedure 1.Roentgenography (X-ray film) Name of the unit Universal roentgenodiagnostic unit (device for roentgenography) -"Kind of the information Roentgenogram - plane image of object on the X-ray film (negative) after its exposure, photo processing and exsiccation X-ray roentgenogram with the contrast study of the object of examination by contrast substance (gastrogram, irrigogram)

2.Roentgenography with the contrast study of the object of examination by contrast substance (gastrography, irrigography etc.) 2 The electroroentgenogra semiconduc phy tor (xenoroentgenograp selenium hy) plates

An electro X-ray roentgenogram - X-ray image of the object (negative) on a usual paper, which is gained after photoexposure of a charged selenium plate, spraying on the plate of a graphite powder, transference of the image from the plate on a paper and fixing it in fumes of an acetone 3 Fluorescent Roentgenoscopy (X- Universal The plane image of screen ray strike-through) roentgenodiagnostic object (positive) on the unit (device for fluorescent screen roentgenoscopy) 4 X-ray Roentgenoscopy Universal The plane image of electronoop with using of ARI or roentgenodiagnostic object (positive) on the tical X-ray television unit with the television screen

The universal roentgenodiagnostic unit (device for roentgenography) and special unit for it (electrororentgenogra ph)

8 transformer strikethrough amplifier of the X-ray or (EOT) image amplifier of the X-ray image (ARI) 5 Dosimetric 1 Digital Digital The X-ray image detectors roentgenography roentgenodiagnostic ciphered in a numeral (roentgenoscopy) units code, which can be transmitted to distance with the help of the computer, to decode, "to strip" of alien details 2. Computer X-ray computer Computer tomogram tomography (C) tomograph X-ray image as cross ) Usual; (axial) edges of a body, b) Spiral; which can be c) Electronic reconstructed in the plane image Table 2 . Additional methods of X-ray examination Name of the receiving device 1 X-ray film Name of procedure Name of the unit Kind of the information The target roentgenogram - target X-ray of a site, where the pathological changes are revealed X-ray film with direct magnification of the object of examination

1 Target Universal roentgenography roentgenodiagnostic unit 2 -"Roentgenography with the direct magnification of the object of examination 3 Tomography Universal (plane, usual) roentgenodiagnostic unit and special device for it

The tomogram - levelby-level image of plane edges of the object of examination on given

9 depth (negative image) The photofluorogram photosnapshot from the fluorescent screen of fluorograph on a rolled film (negative image) - The mammogram - Xray film of breast gland

4 Fluorograph) Photoroentgenogr aphy 5 mammography

Mammograph special roentgenodiagnostic unit for examination of breast gland

Table 3 . Special methods of X-ray examination Name of the receiving device 1 X-ray film Name of procedure 1 Pneumoencephal ography 2 Fistulography Name of the unit Universal roentgenodiagnostic unit Kind of the information

3 Angiography

The pneumoencephalogram X-ray film after introduction of gas in ventricles of the brain -"The fistulogram - X-ray film after introduction of contrast substance in fistulous tracts 1 Universal The angiograms - series roentgenodiagnostic of rapid X-ray films unit and special after catheterization of angiographic device vessels and introduction for it of radiopaque substances 2 Angiographs special roentgenodiagnostic high-speed camera

Recent trends of radiodiagnostic development

10 Digital (numeral) radiodiagnostics - recent trend of development of the radiology. For comprehension of the essence of this procedure and its advantages, we shall address to technology of the X-ray image formation. It, as is known, includes three components: a source of radiation (X-ray tube), object of examination (man), receiver of irradiation (fluorescent screen, X-ray film, selenium plates, electronooptical transformer, dosimetric detectors). However, this system which properly functioning already during many decades, has an essential deficiency. At each stage of passage of irradiation - through the man, receiver of irradiation there are numerous noises, or as the experts say, interior noises. The causes of interior noises are numerous: inhomogeneity of X-ray beam and instability of electrical current, which supplies system, inhomogeneity of object of examination and defects on films and screens. The creators of a new digital method of radiodiagnostics have offered to prolong the technological chain of receiving of the image. The image, which appears on the fluorescent screen, is transmitted to the special device - analog-digital transformer (DT), in which it is coded in a series of numerals, which are transmitted in the computer. The computer according to the special program handles the image: takes out noises, makes it more legible and contrast, takes away fine, interfering details. If necessary the image can be enlarged or diminished. Further the image gets into the decoder or digital-to-analog transformer (ADT), where the X-ray image is again formed from the series of numerals, but is already much more qualitative. The described principle of digital technology is applied at a roentgenoscopy and roentgenography. But especially its advantages expressed at a contrast X-ray examination of vessels - angiography. This procedure even has received the name digital subtraction angiography. The term "subtraction" means " allocation ". The first publications about digital subtraction angiography refer to 1985-1986 years and belong to professor A. Savchenko (Russia).

11 The method is original and simple. Before introducing into the vessel a contrast agent, the numeral note of an explored site of the body is recorded in the storage of computer. The following stage - writing down the image of the same site of the body after introduction of the contrast agent. On last investigation phase will the computer reconstruction of the image is carried out: from the second image allocate the first. On this image only vessels are visible without bones and soft tissues. The image differs by a high quality and all vascular net, which supplies organ or explored site, is superb visible on it, including fine furcations of vascular sprigs. COMPUTER TOMOGRAPHY The computer tomography (CT) is one of the variants of the digital (numeral) roentgenography. The computer X-ray tomography (CTG or CT) is the realization of ideas of the great surgeon N.I.Pirogov: receiving in clinical conditions topography and structure of organs in cross edges. This is the greatest achievement in medicine since the moment of invention of X-rays. South-African physics A.Cormack and English engineer G.Gansfield were awarded by the Nobel Prize in 1979 for invention and clinical trials of computer X-ray tomograph. The history of computer tomography very original and interesting. Its beginning was founded by the work of two American scientists: the neurologist W.Oldendorf and radiologist D.Cool, who in 1960 having utillized as a source of radiation a radionuclide Iodum - 131, have made the reconstruction of the image of cross edge of the skull. However, the image was not so qualitative and in that time this work wasn't appreciated. After three years, in 1963, the by little-known South-African physics A.Cormack has appeared, in which he has offered a mathematical method of reconstruction of the image of brain by means of highly direct X-ray bundle.

12 Opposite previous, this article has paid attention of the experts in the brunch of production of electro musical instruments. One small English firm on production of electro musical instruments, had small, but not bad equipped laboratory under the guidance of unknown engineer G.Gansfield. Having putting aside guitars, scientists for the short period of time have created the new unit, which they have termed scanner. April 19, 1972 on the annual congress of the British institute of radiology by G.Gansfield and doctor G.Ambrous was made the report: "Radiology penetrates into the brain". The success was so evident, that the leading firms on electronics have joined the work at once. In 1974 in USA was designed the tomograph of an essentially new type for examination of the whole body. For the short period all modern clinics of the world were equipped by computer tomographs. Thus in Japan in 1985 per one million of inhabitants there was 25 computer tomographs, in USA - 7. The models of units of V and VI generations with not one but about 200 emitters are now produced. The power processor with velocity of information processing up to 10 million operations per one second is applied. Therefore, the time of scanning was reduced to 40-50 msec. The opportunity to see on the screen of the telemonitor contractions of separate cross layers of heart by thickness 1-2 mm in real time has appeared. New methods of CT - spiral and electronic computer tomography more recently have appeared, where the mechanics is exchanged by electronics, the image is three-dimensional, volumetric, that enables in real time to level-by-level "preparate" the heart. Structure of computer tomograph. The modern construction of X-ray computer tomograph consists of such basic components:

13 1) the holder with built-in X-ray tube, discharge or scintillation dosimetric

detectors, system of receiving, transmission of impulses on the computer. Inside the holder there is a hole, in which the table with the patient moves. The snapshots are made perpendicularly to the long axes of a body, or under the slope 150. 2) computer. 3) 4) the operating board with connected monitor for observation, system of the computer, which except the collecting, processing of signals and information recording and processing. reconstruction of the image maintains and transmits the information on the operating board and the holder. The information from the computer is given out on the telemonitor, camera or magnetic recorder. 5) the additional minicomputer for the analysis of data, emphasize of interesting zones, reconstruction of the image, that is receiving of the image in sagittal or frontal plane, definition of the precise sizes of the pathological focus, measurings of density of the focus. The mechanism of formation of the CT image The patient is in circular system of dosimetric detectors (data units). The pencil X-ray beam scans the human body on a circle or spiral. Transiting through the tissues, the irradiation is reduced according to the density of these tissues. After passage of beams through the body of the patient they get on sensing dosimetric detectors. Electrical impulses are created in detectors, which after amplification transmitted on the computer. According to special algorithm the impulses are transformed into the numeral code, and further in the image of organs and tissues, which is maintained in the storage of computer. The image is transmitted to the telemonitor. the table for scanning equipped with the drive unit for movement of the patient, which is carried out in a horizontal plane automatically on the signal of

14 Contradistinction to traditional X-ray films, the image of organs and tissues on CT remains as axial, i.e. cross. The modern units can give edges by thickness of 1-2 mm. The visual sensing of the image, which arises on the screen of the telemonitor, is possible to process qualitative and quantitative: - to increase the image; - to increase its separate parts; - to measure the precise sizes of the organ or pathological process; - to determine density of the tissue in the relevant sites in standard units; - by mathematical methods of processing it is possible to reconstruct the image of object in three-dimensional, i.e. volumetric. The diagnostics by means of CT is based on the direct roentgenological parameters (localization, shape, sizes) considered the exponent of density or absorption. Exponent of absorption is based on a degree of uptake or reducing of the beam of irradiation at passage through the body of the man. Each tissue depending on density, atomic weight variously absorbs irradiation. That is why for each organ and tissue in norm a designed absorption coefficient (C) according to the Gansfield's scale. According to the scale, C of water accepted for zero, bones, which density is greatest plus 1000 units (U ), air - minus 1000 U . Thereafter, for each organ the medial exponent of absorption coefficient is detected. The separate ability CT depends on a series of the factors: localizations, shape, size and density of pathological process. On CT the tumours and other pathological changes in organs with natural contrast range are well found out. Bones, foreign bodies, stones are the best for diagnostics. The minimal size of formation is 0,5-1 cm if the CA of the affected tissue differs from CA of healthy tissue on 10-15 of U .

15 The method of "amplification" of the image is applied to increasing of separate ability of CT. Intravenously radiopaque drugs are injected, therefore there comes increasing of densitometric difference between the healthy and affected tissues caused by their different blood supply. The method of "amplification" is used for revealing of metastases of malignant tumours in the liver, where the efficiency of this procedure is 25-30 %, for diagnostics of pathological processes in the brain, mediastinum, organs of a small pelvis. Advantages of computer tomography before the usual X-ray examination 1. 2. High sensitivity of CT, which permits to differentiate separate organs and Unlike usual tomography, CT enables to receive the image in the plane of tissues on density near 0,5 %. On X-ray films this exponent comprises 10-20 %. explored edge of 1-2 mm by thickness without stratification of tissues, which disposed above and below. 3. 4. 5. CT enables to receive the precise quantitative information on the sizes and CT enables to estimate not only process, but also its mutual relation with CT enables to receive topograms, that is longitudinal images of explored density both separate organs, and pathological processes. surrounded tissues, for example, invasion of a tumour in the surrounding organs. region like to X-ray films by moving of the patient along a fixed tube. The topograms are used for an establishment of extension of pathological process and determining of the quantity of edges. Methods of intervention radiology It is necessary to note, that CT, as well as the traditional (conventional) radiodiagnostics, is applied not only to reveal the diseases. Under the control of X-ray examination the check of efficiency of the treatment is carried out, the radiotherapy of

16 malignant tumours is planned and some surgical interventions - puncture of organs and pathological processes, the aiming biopsy (slide 38), some operations on vessels and surgical interventions on organs of the abdominal cavity and small pelvis are performed. The basic directions of development of the intervention radiology are: - endovascular; - endobronchial; - endobiliary; - endourinary; - endoesophageal; - percutaneous drainage of cysts and abscesses under the radial control; - aspiration biopsy under the radial control X-ray endovascular surgery - new progressive direction in radiology, which except diagnostics of the diseases provides also a medical intervention on the vessels. The method of catheter introduction in the vessel and leading the medicinal remedies to the thrombus is known for a long time. In 1964 the American scientists Ch.Dotter and M.Gatkins have offered a procedure of the catheter vasodilatation in occlusion of artery by atherosclerotic plaque. In 1974 the German doctor A. Gruntzig has designed for this purpose the special bladder-type catheter, which being dilated squash the atherosclerotic plaque and the flotation ability of the vessel was recovered. However, the cause of the illness has remained, and soon on the place of an old plaque occurred new. In the beginning of 1985 in Moscow by professor I.Rabkin was the begun a new trend of X-ray endovascular prosthetics - application of the nitinol prostheses. This idea has arised since 40-th, when the Soviet academician G.Kurdyumov has revealed the special type of transformations in metal alloys. It was found out, that some alloys obtain the effect of "memorization" of the shape. And if they at particular

17 temperature deform, in further, at warming they reduce the shape. Among many alloys the most suitable for the embodiment of the mentioned idea was nitinol. The purpose of the method in the following: the nitinol spiral according to the diameter of the vessel is produced at temperature 37-40o C, that corresponds to the temperature of the human body. Then, having cooled, the spiral rectifies in direct piece of wire, which pushes through the catheter under the check of X-ray unit to the place of waist of the vessel stenosis. As soon as the wire begins to heat up by the blood to the temperature of the body, it "remembers" the former shape and turns in the spiral, which becomes a skeleton and prevents the vessel stenosis and the development of an atherosclerotic plaque in this place. Today this procedure is applied in vascular surgery with great success.