RTC on RADIATION PROTECTION OF PATIENTS FOR RADIOGRAPHERS Accra, Ghana, July 2011

Image Quality and Patient Dose

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International Atomic Energy Agency

Overview
To become familiar with the factors that
determine the image clarity and the way the image quality can be improved

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Imaging quality
Efficient diagnosis requires
acceptable noise good image contrast sufficient spatial resolution These factors are linked Objective measurement of quality is difficult

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Factors affecting image quality

Blur or Unsharpness

Contrast

Image quality

Distortion & artifact

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Noise

Image contrast

Low Contrast

Medium Contrast

High Contrast

Image contrast refers to the fractional difference in optical density of brightness between two regions of an image
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Some factors influencing contrast

Radiographic or subject Image contrast

contrast

Tissue thickness Tissue density Tissue electron density Effective atomic number Z X Ray energy in kVp X Ray spectrum (filtration) Scatter rejection Collimator Grid

The radiographic contrast

plus : Film characteristics Screen characteristics Windowing level of CT and DSA

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Technique factors (1)

Peak voltage value has an influence on the
beam hardness (beam quality) It has to be related to medical question
What is the anatomical structure to be
investigated? What is the contrast level needed? For a thorax examination : 110 - 120 kV is suitable to visualize the lung structure However only 65 kV is necessary to see bone structure
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Technique factors (2)

The higher the energy, the greater the penetrating
power of X Rays At very high energy levels, the difference between bone and soft tissue decreases and both become equally transparent Image contrast can be enhanced by choosing a lower kVp so that photoelectric interactions are increased Higher kVp is required when the contrast is high (chest)
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Technique factors (3)

The mAs controls the quantity of X Rays (intensity
or number of X Rays) X Ray intensity is directly proportional to the mAs Over or under-exposure can be controlled by adjusting the mAs If the film is too white, increasing the mAs will bring up the intensity and optical density

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Receptor contrast
The film as receptor has a major role to play in
altering the image contrast There are high contrast and high sensitivity films The characteristic curve of the film describes the intrinsic properties of the receptor (base + fog, sensitivity, mean gradient, maximum optical density) N.B.: Film processing has a pronounced effect on fog and contrast
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Image Contrast
Difference in signal pixel value, film
density

High

Low
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Video monitor
The video monitor is commonly used in
fluoroscopy and digital imaging
The display on the monitor adds flexibility in the choice
of image contrast The dynamic range of the monitor is limited (limitation in displaying wide range of exposures)

Increased flexibility in displaying image contrast is

achieved by adjustment of the window level or grey levels of a digital image

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Blur or lack of sharpness

The boundaries of an organ or lesion may be
very sharp but the image shows a lack of sharpness Different factors may be responsible for such a degree of fuzziness or blurring The radiologist viewing the image might express an opinion that the image lacks detail or resolution (subjective reaction of the viewer to the degree of sharpness present in the image)
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Resolution
Smallest distance that two objects can be
separated and still appear distinct Example of limits
Film/screen: 0.01 mm CT: 0.5 mm

Other definition: Point-spread function

Characteristic of a point object Point object expected to be point in image Blurring due to imperfections of imaging system
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Factors affecting image sharpness

Geometric Unsharpness

Object Unsharpness

Image Unsharpness

Motion Unsharpness

Subject Unsharpness

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Resolution and Focal Spot Size

Penumbra More blur

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Appearance of image

Less blur
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Measuring Resolution

Line pair test object

One line pair

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Geometric blur
If the focal spot is infinitesimally small, the blur is minimized because of minimal geometric bluntness As the focal spot increases, the blur in the image increases

Small focal spot

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Large focal spot

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Geometric blur
Another cause of lack of geometric sharpness is
the distance of the receptor from the object Moving the receptor away from the object results in an increased lack of sharpness N.B.: The smaller the focal size and closer the contact between the object and the film (or receptor), the better the image quality as a result of a reduction in the geometric sharpness

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Lack of sharpness in the subject

Not all structures in the body have well-defined
and separate boundaries (superimposition essentially present in most situations) The organs do not have square or rectangular boundaries The fidelity with which details in the object are required to be imaged is an essential requirement of any imaging system The absence of sharpness, in the subject/object is reflected in the image
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Lack of sharpness due to motion (1)

Common and understandable blur in medical
imaging Patient movement :
uncooperative child organ contraction or relaxation heart beating, breathing etc.

Voluntary motion can be controlled by keeping

examination time short and asking the patient to remain still during the examination
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Lack of sharpness due to motion (2)

Shorter exposure times are achieved by the use of
fast intensifying screens N.B.: Faster screens result in loss of details (receptor sharpness) Further, the use of shorter exposure time has to be compensated with increased mA to achieve a good image This often implies use of large focal spot (geometric sharpness)
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Distortion and artifacts

Unequal magnification of various anatomical
structures Inability to give an accurate impression of the real size, shape and relative positions Grid artifact (grid visualized on the film) Light spot simulating microcalcifications (dust on the screen) Bad film screen contact, bad patient positioning (breast)
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Noise
Defined as uncertainty or imprecision of the
recording of a signal Impressionist painting: precision of object increases with number of dots X Ray imaging: when recorded with small number of X- photons has high degree of uncertainty,more photons give less noise Other sources of noise:
Grains in radiographic film Large grains in intensifying screens Electronic noise of detector or amplifier
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Noise

Decreasing radiation intensity

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Increasing noise
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Contrast & Noise

Contrast

Noise

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Radiography Issues
Correct positioning
Improves diagnosis and reduces retakes PRE-exposure collimation Minimises unnecessary tissue dose With CR/DR, there is a temptation to postexposure (electronically) collimate RESIST THIS!!

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Summary
Different technical and physical factors may
influence the image quality by impairing the detection capability of the anatomical structures useful for diagnosis (increasing the image unsharpness)
Some factors depend on the receptor, some others are
more related to the radiographic technique

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Patient dose assessment

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International Atomic Energy Agency

Overview
To become familiar with the patient dose
assessment and dosimetry instrument characteristics.

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Parameters influencing patient exposure

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International Atomic Energy Agency

Essential parameters influencing patient exposure

Tube voltage Tube current Effective filtration Exposure time

Kerma rate [mGy/min] [min]

Kerma [Gy]

Field size

[m2]

Area exposure product [Gy m2 ]

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Factors in conventional radiography: beam, collimation

Beam energy
Depending on peak kV and filtration Regulations require minimum total filtration to absorb
lower energy photons Added filtration reduces dose Goal should be use of highest kV resulting in acceptable image contrast

Collimation
Area exposed should be limited to area of CLINICAL
interest to lower dose Additional benefit is less scatter, better contrast
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Factors in conventional radiography: grid,patient size

Grids
Reduce the amount of scatter reaching image receptor But at the cost of increased patient dose Typically 2-5 times: Bucky factor or grid ratio Thickness, volume irradiatedand dose increases with
patient size Except for breast (compression), no control Technique charts with suggested exposure factor for various examinations and patient thickness helpful to avoid retakes Use of AEC exposure
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Patient size

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Factors affecting dose in fluoroscopy

Beam energy and filtration Collimation Source-to-skin distance
Inverse square law: maintain max distance from patient

Patient-to-image intensifier
Minimizing patient-to- I I will lower dose But slightly decrease image quality by increased scatter

Image magnification
Geometric and electronic magnification increase dose

Grid
If small sized patient (les scatter) perhaps without grid

Beam-on time!
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Factors affecting dose in CT

Beam energy and filtration

120-140 kV; shaped filters

Collimation or section thickness

Post-patient collimator will reduce slice thickness
imaged but not the irradiated thickness

Number and spacing of adjacent sections Image quality and noise

Like all modalities: dose increase=>noise decreases
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Factors affecting dose in spiral CT

Factors for conventional CT also valid Scan pitch

Ratio of couch travel in one rotation divided by
slice thickness If pitch = 1, doses are comparable to conventional CT Dose proportional to 1/pitch

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Patient dosimetry methods

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International Atomic Energy Agency

Patient dosimetry

Radiography: entrance surface dose ESD

Output factors Dose area product (DAP) Fluoroscopy: Dose - Area Product (DAP) CT: Computed Tomography Dose Index (CTDI) Dose length product (DLP)
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From ESD to organ and effective dose

Except for invasive methods, no organ doses can be
measured The only way in radiography: measure the Entrance Surface Dose (ESD) Use mathematical models to estimate internal dose. Mathematical models based on Monte Carlo simulations Dose to the organ tabulated as a fraction of the entrance dose for different projections Since filtration, field size and orientation play a role: long lists of tables (See NRPB R262 and NRPB SR262)
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From DAP to organ and effective dose

In fluoroscopy: moving field, measurement of
Dose-Area Product (DAP) In similar way organ doses calculated by Monte Carlo modelling Based on mathematical model Conversion coefficients estimated as organ doses per unit dose-area product Again numerous factors are to be taken into account such as projection, filtration, Once organ doses are obtained, effective dose is calculated following ICRP103
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Dose measurements: how to measure dose indicators ESD, DAP,CTDI

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Measurements of Radiation Output

X Ray tube

Filter

SDD
Ion. chamber

Table top
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Lead slab Phantom (PEP)

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Measurements of Radiation Output

Operating conditions Consistency check The output as a function of kVp The output as a function of mA The output as a function of exposure time

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Measurement of entrance surface dose

Includes backscatter (~30%)

TLD, solid state dosimeter or ion chamber

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Dose Area Product (DAP)

Transmission ionization chamber

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Dose Area Product (DAP)

0.5 m
1m 2m Air Kerma: 40*103 Gy 10*103 Gy Area: 2.5*10-3 m2 10*10-3 m2 Area 100 Gy m2 100 Gy m2 exposure product

2.5*103 Gy 40*10-3 m2 100 Gy m2

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Calibration of a Dose Area Product (DAP)

Film cassette

Ionization chamber

10 cm
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Levels of Dosimetry
Level 1 - published tables Level 2 - Monte Carlo tables using known
data Level 3 - direct measurement of skin dose Level 4 - humanoid phantom measurements with TLD

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Level 1 - Published Dose Tables

ICRP, NCRP and various books have
tables of typical doses for various x-rays Tables show organ doses and sometimes effective dose The data is usually old, from x-rays made with slower film/screen systems than in current use Still useful as a guide
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Level 2 - Monte Carlo Systems

Provide organ doses, and effective dose Use calculated data but with user entry of
various parameters : HVL, kVp skin dose or free-in-air exposure at skin distance FSD, field size and position

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Monte Carlo Systems

Various computer programs and lookup
tables, eg. TISSDOSE, XDOSE, PCXMC Most users do not know the actual values for input variables, so often must use assumed values HVL, kVp, FSD, field size easy to assume kVp/mAs and field size not always easy to assume
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Typical Radiology Doses (Melbourne Data)

Procedure Abdomen (AP) Chest (PA) Lumbar spine AP/Lat Pelvis (AP) Thoracic spine (lat.) Mammography (4 views)

ESD (mGy) 2.5 0.15 3.2/4.0 1.7 2.6 4.4

Eff. Dose (mSv) 0.35 0.023 0.23/0.11 0.29 0.097 0.44

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XDose

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PCXMC

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ImPACT CT Dose

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Summary
In this lesson we learned the factors
influencing patient dose, and how to have access to an estimation of the detriment through measurement of entrance dose, dose area product or specific CT dosimetry methods.

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