17-Feb-20

Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics

Course
12 -19 October 2006

BASIC PHYSICS OF X- RAYS

X-Ray Tubes, Generators MODALITIES

FLUOROSCOPY
X-Ray Production
CT
X-Ray Interactions
MRI
Computers and PACS
MAMMOGRAPHY
Screen Film Radiography
US
Image Quality
Digital Radiography

RAD PROTECTION, SAFETY, DOSIMETRY

RAD SAFETY
RAD PROTECTION
RAD BIOLOGY
RAD DOSIMETRY

Fluoroscopy - Chapter 9

a copy of this lecture may be found at:

http://courses.washington.edu/radxphys/PhysicsCourse.html

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 1
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Real-Time Imaging

 Fluoroscopy is an imaging procedure that allows real-time x-ray

viewing of the patient with high temporal resolution

 Uses TV technology, which provides 30 frames per second imaging

 Allows acquisition of a real-time digital sequence of images (digital

video), that can be played back as a movie loop

 Cine cameras offer up to 120 frame per second acquisition rates

using 35-mm cine film. Digital cine also available

Fluoroscopic Imaging Chain Components

c.f. Bushberg, et al.

The Essential Physics
of Medical Imaging, 2nd
ed., p. 232.
4

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 2
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

The Image Intensifier (II)

 Four principal components:

 (a) a vacuum bottle to keep the
air out
 (b) an input layer that converts
the x-ray signal to electrons
 (c) electronic lenses that focus
the electrons, and
 (d) an output phosphor that
converts the accelerated
electrons into visible light

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 233.

Input Screen

 The input screen of the II

consists of 4 different layers:

 (a) vacuum window, a 1 mm

aluminum window that is part of
the vacuum bottle

 keeps the air out of the II

 curvature designed to
withstand the force of the air
pressing against it

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 233.

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 3
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Input Screen

(b) support layer, strong enough to

support the input phosphor and
photocathode layers, but thin
enough to allow most x-rays to
pass through it
 0.5 mm of aluminum, is the
first component in the
electronic lens system, and
its curvature is designed for
accurate electronic focusing

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 233.

Input Screen

(c) input phosphor, whose function

is to absorb the x-rays and
convert their energy into visible
light
 cesium iodide (CsI) is used
 long, needle-like crystals
which function as light pipes,
channeling the visible light
toward the photochathode
with minimal lateral
spreading

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 233.

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 4
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Input Screen

(d) photocathode is a thin layer of

antimony and alkali metals that
emits electrons when struck by
visible light
 10 to 20% conversion
efficiency

 Varying size FOV (16”, 12”, 9”,

7”, 6” and so on)

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 233.

Input Phosphor Energy Conversion

Aluminum Support

Photocathode

CsI Needles

Figure courtesy from Jonathan Tucker, Brooke Army

Medical Center, SA, TX 10

10

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 5
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Input Phosphor Energy Conversion

60 keV X-Ray

Aluminum Support

Photocathode

CsI Needles Figure courtesy from Jonathan Tucker, Brooke Army

Medical Center, SA, TX
11

11

Input Phosphor Energy Conversion

Aluminum Support

3,000 light photons

 = ~ 420 nm

Photocathode

CsI Needles Figure courtesy from Jonathan Tucker, Brooke Army

Medical Center, SA, TX 12

12

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 6
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Input Phosphor Energy Conversion

Aluminum Support

Photocathode

~ 300-600 electrons

CsI Needles To
Anode
Figure courtesy from Jonathan Tucker,
Brooke Army Medical Center, SA, TX
13

13

Electron Optics

 Electrons accelerated by an
electric field
 Energy of each electron is
substantially increased and this
gives rise to electron gain
 Focusing is achieved using an
electronic lens, which requires
the input screen to be a curved
surface, and this results in
unavoidable pincushion
distortion of the image

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 235.
14

14

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 7
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Electron Optics

 The G1, G2, G3 electrodes along

with the input screen and the
anode near the output phosphor
comprise the five-component
electronic lens system of the II

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 235.
15

15

Electron Optics

 The electrons under the

influence of the 25K to 35K V
electric field, are accelerated and
arrive at the anode with high
velocity and considerable kinetic
energy
 After penetrating the very thin
anode, the energetic electrons
strike the output phosphor

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 235.
16

16

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 8
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

The Output Phosphor

 The output phosphor is made of

zinc cadmium sulfide
 Anode is a very thin coating of
aluminum on the vacuum side of
the output phosphor
 Each electron causes the
emission of approximately 1000
light photons from the output
phosphor
 2.5 cm diameter output phosphor

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 235.
17

17

The Output Phosphor

 The reduction in image diameter

leads to amplification

 Minification gain of an II is the

ratio of the area of the input
phosphor to that of the output
phosphor,
 e.g., 9’’ input phosphor, 1’ output
phosphor, area is square of the
diameter ratio, minification gain is
81

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 235.
18

18

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 9
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

The Output Phosphor

 The output phosphor is coated

right onto the output window

 Some fraction of the light emitted

by the output phosphor is reflected
at the glass window

 Light bouncing around the output

window is called veiling glare, and
can reduce image contrast

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 235.
19

19

Raphex 2001 Diagnostic Question

 D24-D28. For the image intensifier
shown, match the following: (answers
may be used more than once)
 A. Light photons.
 B. X-ray photons.
 C. Microwaves.
 D. Electrons.
 E. Infrared photons.

 D24. I represents
 D25. II represents
 D26. III represents
 D27. IV represents
 D28. V represents

20

20

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 10
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Characteristics of Image Intensifier Performance

Conversion Factor

 Function of II is to convert an x-ray image into a minified light image

 Several characteristics that describe how well the II performs this

function
Light out of image intensifier (cd/m2)
Conversion Factor =
Exposure rate into image intensifier (mR/sec)

 Defined as a measure of the gain of an image intensifier

 ratio of light output to exposure rate input
 100 to 200 for new image intensifier
 Degrades over time, ultimately can lead to II replacement

21

21

Characteristics of Image Intensifier Performance

Brightness Gain

 BG = minification gain x electronic gain (flux gain)

 Minification gain = increase in image brightness that results from

reduction in image size from the input phosphor to output phosphor
size

 (di/do)2, di is input diameter which varies, do is output diameter

typically 2.5 cm

 For 30 cm (12”) II, minification gain = 144

22

22

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 11
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Characteristics of Image Intensifier Performance

Brightness Gain

 BG = minification gain x electronic gain (flux gain)

 Electronic gain or flux gain (acceleration of the electrons from

photocathode to output phosphor) is typically 50

 The brightness gain therefore ranges from about 2,500 – 7,000

 As the effective diameter of the input phosphor decreases

(magnification increases), the brightness gain decreases

23

23

Characteristics of Image Intensifier Performance

Field of View/Magnification Modes
 FOV specifies the size of the input phosphor of the image intensifier
 Different sizes: 23 cm (9”), 30 cm (12”), 35 cm (14”), 40 cm (16”)
 Magnification is accomplished electronically using electronic focusing
that projects part of the input layer onto the output phosphor
 Since brightness gain decreases in mag. mode, the x-ray exposure
rate is boosted. (12/9)2 = 1.8, (12/7)2 = 2.9

c.f. Bushberg, et al. The Essential Physics

of Medical Imaging, 2nd ed., p. 237.

http://rpop.iaea.org/RPOP/RPoP/Content/InformationFor/HealthProfessionals/1_Radiology/Fluoroscopy.htm
24

24

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 12
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

2. Raphex 2000 Diagnostic Question

 D29. In fluoroscopy, switching from the 9 inch to the 6 inch field-of-

view (FOV) results in _______in the T.V. resolution and ________in
the patient entrance radiation exposure.

 A. An increase, a decrease
 B. A decrease, an increase
 C. An increase, an increase
 D. A decrease, a decrease
 E. An increase, no change

25

25

Optical Coupling
Distribution Mechanism
 Parallel rays of light enter the
optical chamber, are focused by
lenses, and strike the video
camera where an electronic
image in produced

 A partially silvered mirror is

used to shunt the light emitted
by the image intensifier to an
accessory port

 CCD detectors are now used

instead of video cameras

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 239.
26

26

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 13
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Video Camera and Monitor

General Operation

c.f. Schueler- AAPM/RSNA Physics Tutorial for Residents: General Overview of Fluoroscopic
Imaging, Radiographics 2000; 20:1115-1126.
27

27

Video Cameras
General Operation

 Analog video systems typically have 30 frames/sec operation, but they

work in an interlaced fashion to reduce flicker, the perception of the
image flashing on and off

 The human eye-brain system can detect temporal fluctuations slower

than about 47 images/sec, and therefore at 30 frames/sec flicker
would be perceptible

 With interlaced systems, each frame is composed of two fields and

each field is refreshed at a rate of 60 times per second, which is fast
enough to avoid perception of flicker

28

28

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 14
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Video Cameras
LAG

 Lag means that each new TV

image actually contains residual
image information from the last
several frames

 Lag is good and bad

 Lag acts to smooth the quantum

noise in the image, but can also
cause motion blurring

c.f. Van Lysel. - AAPM/RSNA Physics Tutorial for Residents: Fluoroscopy: Optical Coupling and the
Video System, Radiographics 2000; 20:1769-1786. 29

29

Video Cameras
Video Resolution

 Spatial resolution of a video in the vertical direction (top to bottom)

of the TV image is governed by the number of scan lines

 By convention, 525 lines are used in N. America for TV

 490 lines usable

 In the early days of TV, a man named Kell determined that

about 70% of theoretical video resolution is appreciated

visually, and this psychophysical effect is now called the Kell
factor

 If higher resolution needed such as in angio, 1024 lines could be

used or higher

30

30

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 15
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Video Cameras
Video Resolution

 490 x 0.7 = 343 lines or 172 line pairs useful for resolution

 For 9” field, resolution = 172 lp/229 mm = 0.75 lp/mm

 17 cm or 7” field, resolution is 1.0 lp/mm
 12 cm or 5” field, resolution is 1.4 lp/mm

31

31

Video Cameras
Video Resolution

 The horizontal resolution is determined by how fast the video

electronics can respond to changes in light intensity

 This is influenced by the camera, the cable, the monitor but the
horizontal resolution is governed by the bandwidth of the system

32

32

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 16
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Video Cameras
Video Resolution

 The time necessary to scan each video line (525 lines at 30

frame/sec) is 63 msec
 11 msec required for horizontal retrace, 52 msec available

 To achieve 172 cycles in 52 msec, the bandwidth required is 172

cycles/52 x 10-6 sec = 3.3 x 106 cycles/sec = 3.3 MHz

 Higher bandwidths are required for high-line video systems

33

33

Raphex 2001 Diagnostic Question

 D29. The maximum resolution of fluoroscopy images displayed on

television in the 6" field of view with a 1024 line system with a Kell
factor of 0.7 is about ______ lp/mm.
 A. 0.7
 B. 1.2
 C. 1.8
 D. 2.4
 E. 2.9

 1024 x 0.7 = 717 lines or 358 line pairs useful for resolution
 For 6” field, resolution = 358 lp/6’’*25.4 mm = 2.35 lp/mm

34

34

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 17
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Take Home Points

 Fluoroscopy is a live imaging procedure

 Image Intensifier main component and consists of the input

phosphor, electronic lens system and output phosphor
 Input phosphor – Cesium Iodide, converts x-rays to light
 Photocathode – converts light into electrons
 Output phosphor – Zinc cadmium sulphide, converts electrons into
light

 Artifacts – pincushion distortion, veiling glare, lag

35

35

Take Home Points

 Brightness gain = minification gain x electronic (flux) gain

 Several magnification modes available, typically exposure rate

increases with magnification

 Video camera produces the electronic image which we see on the

TV monitor
 Use interlaced scanning to avoid flicker
 Horizontal (determined by bandwidth) and vertical (determined by the
number of scan lines) video resolution

36

36

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 18
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Flat Panel Digital Fluoroscopy

 Flat panel devices are thin film

transistor (TFT) arrays that are
rectangular in format and are
used as x-ray detectors

 CsI, a scintillator is used to

convert the incident x-ray beam
into light

 TFT systems have a

photodiode at each detector
element which converts light
energy to an electronic signal

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 242.
37

37

Flat Panel Digital Fluoroscopy

 Flat panel detectors would

replace the image intensifier,
video camera, and other
peripheral devices

 Resolution would not change

when FOV is changed since no
geometric magnification,
collimation used to magnify
image

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 242.
38

38

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 19
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Flat Panel Digital Fluoroscopy

 Possible to have dual-use flat-panel systems with pixels small
enough for radiography (150-200 mm) and
 By binning pixels into one large pixel provides a detector useful for
fluoroscopy (200-300 mm)

http://www.medical.philips.com/us/products/cardiovas http://www.gehealthcare.com/usen/xr/cardiovas
cular/products/fd20_radio/fd20_radio.html cular/products/innova4100sys.html
39

39

Peripheral Equipment

 Photo-spot camera
 used to generate images on
photographic film
 100-mm cut film or 105-mm
roll film
 full resolution of the II system,
hardly seen nowadays

Geise, R. A. Radiographics 2001;21:227-236 40

40

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 20
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Peripheral Equipment

 Digital photo-spot
 high resolution, slow-scan TV cameras in which the TV signal is
digitized and stored in computer memory
 Or CCD cameras with 10242 or 20482 pixel formats
 near-instantaneous viewing of the image on a video monitor
 allows the fluoroscopist to put together a number of images to
demonstrate the anatomy important to the diagnosis
 digital images can be printed on a laser imager

41

41

Peripheral Equipment

 Spot-film devices
 attaches to the front of the II,
and produces conventional
radiographic screen-film
images, used when large
FOV is needed
 better resolution than images
produced by II

Geise, R. A. Radiographics 2001;21:227-236

42

42

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 21
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Peripheral Equipment

 Cine-radiography cameras
 attaches to a port, can record a
very rapid sequence of images
on 35-mm film
 used in cardiac studies, 30
frames/sec to 120 frames/sec or
higher

Geise, R. A. Radiographics 2001;21:227-236

43

43

Peripheral Equipment

 Cine-radiography cameras
 uses very short radiographic
pulses
 digital cine are typically CCD-
based cameras that produce a
rapid sequence of digital images
instead of film sequence

Geise, R. A. Radiographics 2001;21:227-236

Schueler, B. A. Radiographics
2000;20:1115-1126

44

44

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 22
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Fluoroscopy Modes of Operation

 Continuous fluoroscopy
 continuously on x-ray beam, 0.5 – 4 mA or higher
 display at 30 frames/sec, 33 msec/frame acquisition time
 blurring present due to patient motion, acceptable
 10 R/min is the maximum legal limit

45

45

Fluoroscopy Modes of Operation

 High dose rate fluoroscopy

 specially activated fluoroscopy
 20 R/min is the maximum legal limit
 audible signal required to sound
 used for obese patients

46

46

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 23
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Fluoroscopy Modes of Operation

 Pulsed fluoro:
 series of short x-ray pulses, 30 pulses at ~10 msec per pulse
 exposure time is shorter, reduces blurring from patient motion
 Can be used where object motion is high, e.g., positioning
catheters in highly pulsatile vessels
 15 frames/sec, 7.5 frames/sec also available

47

47

Fluoroscopy Modes of Operation

 Pulsed fluoro:
 Variable frame pulsed fluoroscopy is instrumental in reducing
dose
 Ex., initially guiding the catheter up from the femoral artery to the
aortic arch does not require high temporal resolution and 7.5
frames/sec could potentially be used instead of 30 frames/sec
 dose savings of (7.5/30) 25%

48

48

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 24
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Fluoroscopy Modes of Operation

Frame Averaging

 Fluoroscopy systems provide excellent temporal resolution

 However, fluoroscopy images are relatively noisy, and in some

applications it is beneficial to compromise temporal resolution for
lower noise images

c.f.Pooley et. al. - AAPM/RSNA Physics Tutorial for Residents: Diigtal Fluoroscopy, Radiographics
2001; 21:521-534.
49

49

Fluoroscopy Modes of Operation

Frame Averaging
 This can be achieved by averaging a series of images or frames
 Real-time averaging in the computer memory for display
 Can cause noticeable image lag but noise in image is reduced as
well
 Could also reduce dose in some circumstances

c.f.Pooley et. al. - AAPM/RSNA Physics Tutorial for Residents: Diigtal Fluoroscopy, Radiographics
2001; 21:521-534.
50

50

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 25
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Fluoroscopy Modes of Operation

Last-Frame Hold

 Last-frame hold
 when the fluoroscopist takes his or her foot off the fluoroscopy
pedal, rather than seeing a blank monitor, last-frame-hold
enables the last live image to be shown continuously
 useful at training institutions
 no unnecessary radiation used on patient

51

51

Fluoroscopy Modes of Operation

Road Mapping

 Road Mapping
 software-enhanced variant of the last-frame-hold feature
 side-by-side video monitors, one shows captured image, the
other live image
 In angiography, subtracted image can be overlayed over live
image to give the angiographer a vascular “road map” right on the
fluoroscopy image
 is useful for advancing catheters through tortuous vessels

52

52

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 26
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Fluoroscopy Modes of Operation

Road Mapping

c.f.Pooley et. al. - AAPM/RSNA Physics Tutorial for Residents: Diigtal Fluoroscopy, Radiographics
2001; 21:521-534.
53

53

Fluoroscopy Modes of Operation

Digital Subtraction Angiography (DSA)

 Real-time subtraction of pre- and post-contrast images is called DSA

 Used clinically for vessel visualization

c.f.Pooley et. al. - AAPM/RSNA Physics Tutorial for Residents: Diigtal Fluoroscopy, Radiographics
2001; 21:521-534.
54

54

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 27
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Fluoroscopy Modes of Operation

Digital Subtraction Angiography (DSA)

c.f.Pooley et. al. -

AAPM/RSNA
Physics Tutorial for
Residents: Diigtal
Fluoroscopy,
Radiographics 2001;
21:521-534.

55

55

Automatic Brightness Control

 The purpose of the automatic brightness control (ABC) is to keep

the brightness of the image constant at monitor

 It does this by regulating the x-ray exposure rate (control kVp, mA or

both)

 Automatic brightness control triggers with changing patient size and

field modes

56

56

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 28
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Automatic Brightness Control

 The top curve increases mA

more rapidly than kV as a
function of patient thickness,
and preserves subject
contrast at the expense of
higher dose

 The bottom curve increases

kV more rapidly than mA with
increasing patient thickness,
and results in lower dose, but
lower contrast as well

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 247.

57

57

Raphex 2003 Diagnostic Question

 D36. A 9-in. multi-mode image intensifier (II) is switched to the 6-in.

mode. As a result, the image will be ________ , and the automatic
brightness control system (ABC) will _________ the exposure to the
II and the patient.

 A. magnified, decrease
 B. magnified, increase
 C. minified, increase
 D. magnified, not change
 E. minified, decrease

58

58

Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 29
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Raphex 2000 Diagnostic Question

 D30. Pulsed fluoroscopy at 15 fps is utilized primarily to

___________.

 A. Reduce motion blur.

 B. Increase kW rating.
 C. Increase kVp stabilization.
 D. Reduce focal spot sizes.
 E. Reduce patient dose.

59

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Image Quality
Spatial Resolution

 The limiting spatial resolution is

the size of the smallest object
that an imaging system can
resolve

 The limiting resolution of

modern image intensifiers is
between 4 and 5 cycles/mm

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 248.

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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 30
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Image Quality
Contrast Resolution

 The contrast resolution of fluoroscopy is low by comparison to

radiography, because the low exposure levels produce images with
relatively low signal-to-noise ratio (SNR)

 Contrast resolution is typically measured subjectively by viewing

contrast-detail phantoms under fluoroscopy

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Image Quality
Contrast Resolution

 Contrast resolution is increased when higher exposure rates are

used, but the disadvantage is more radiation dose to the patient

 Fluoroscopic systems with different dose settings allow the user

flexibility from patient to patient to adjust the compromise between
contrast resolution and patient exposure

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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 31
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Image Quality
Temporal Resolution

 Fluoroscopy has excellent temporal resolution, that is over time and

is the reason for its existence

 Blurring in the time domain is typically called image lag

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Image Quality
Temporal Resolution
 Lag implies that a fraction of the image data from one frame carries
over into the next frame
 Video cameras such as the vidicon demonstrate a fair amount of lag

c.f. Van Lysel. -

AAPM/RSNA Physics
Tutorial for Residents:
Fluoroscopy: Optical
Coupling and the
Video System,
Radiographics 2000;
20:1769-1786.

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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 32
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Image Quality
Temporal Resolution

 Lag in general is undesirable, beneficial for DSA

 Frame averaging improves contrast resolution at the expense of

temporal resolution

 With DSA and digital cine, cameras with low-lag performance

(plumbicons or CCD cameras) are used to maintain temporal
resolution

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Raphex 2003 Diagnostic Question

 D37. For fluoroscopy performed in the 6-in. II mode and displayed

on a 525 line TV monitor, spatial resolution is most limited by the
_______.

 A. Scatter from the patient

 B. Grid
 C. II tube
 D. Optical system
 E. TV system

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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 33
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Radiation Dose

 Patient Dose
 The maximum exposure rate permitted in the US is governed by
the Code of Federal Regulations (CFR), and is overseen by the
Center for Devices and Radiological Health (CDRH), a branch of
the Food and Drug Administration (FDA)
 The maximum legal entrance exposure rate for normal fluoroscopy
to the patient is 10 R/min
 For specially activated fluoroscopy, the maximum exposure rate
allowable is 20 R/min

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Radiation Dose

 Patient Dose

 Typical entrance exposure

rates for fluoroscopic
imaging are
 About 1 to 2 R/min for
thin (10-cm) body parts
 3 to 5 R/min for the
average patient
 8 to 10 R/min for the
heavy patient

 Maximum dose at 120 kVp

for most vendors

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 252.

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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 34
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Radiation Dose
Dose to Personnel

 Rule of Thumb: standing 1 m from

the patient, the fluoroscopist receives
from scattered radiation (on the
outside of apron) approximately
1/1,000 of the exposure incident
upon the patient

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 253.
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Radiation Dose
Dose to Personnel

 The scatter field incident upon the

radiologist while performing a
fluoroscopic procedure is shown

 A radiologist of average height, 178

cm (5’10”) is shown overlaid on the
graph and key anatomic levels are
indicated

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 253.
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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 35
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Radiation Dose
Dose to Personnel

 The dose rate as a function of height

above the floor in the room is shown
for 6 different distances D,
representing the distance between
the edge of the patient and the
radiologist

 80 kVp beam and 20 cm patient

thickness assumed for calculation

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 253.
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Radiation Dose
Dose to Personnel

 Stepping back from the radiation field

helps reduce dose to the
fluoroscopist

 Dose-area product (DAP)

(mGy•cm2) meters and Air Kerma
display (mGy) can be used to
provide real-time estimate of the
amount of radiation the patient has
received

c.f. Bushberg, et al. The Essential Physics of Medical

Imaging, 2nd ed., p. 253.
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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 36
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Raphex 2002 Diagnostic Question

 D36. The fluoroscopic operating factors displayed on a monitor are

120 kVp and 10 mA. Which of the following is true?

 A. The skin entrance dose is unusually low.

 B. The five-minute timer is broken.
 C. The skin entrance dose is extremely high.
 D. The display must be wrong.
 E. The anti-scatter grid is not in the beam.

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Fluoroscopy Suites

 Gastrointestinal Suites
 R and F room, large table
that can be rotated from
horizontal to vertical to put
the patient in a head-down
or head-up position

 II above or under the table,

spot film device usually
there

Schueler, B. A. Radiographics 2000;20:1115-1126

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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 37
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Fluoroscopy Suites

 Remote Fluoroscopy Rooms

 Designed for remote
operation by the radiologist

 Tube above table, II under

table

 Reduce dose to the

physician and no lead
apron needed

Schueler, B. A. Radiographics 2000;20:1115-1126

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Fluoroscopy Suites

 Peripheral Angiography Suites

 Table floats, allows patient
to be moved from side to
side and head to toe
 C-arm or U-arm
configuration
 30 to 40 cm image
intensifier used
 Power injectors are
normally ceiling- or table-
mounted

Schueler, B. A. Radiographics 2000;20:1115-1126

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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 38
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Fluoroscopy Suites

 Cardiology Catheterization Suite

 Similar to angiography suite,
23 cm II used to permit more
tilt in cranial caudal direction

 Cine cameras used, biplane

rooms common

Schueler, B. A. Radiographics 2000;20:1115-1126

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Fluoroscopy Suites

 Biplane Angiographic Systems

 Two complete x-ray tube/II
systems used, PA and Lateral

 Simultaneous acquisition of 2
views allows a reduction of the
volume of contrast media
injected in patient

Schueler, B. A. Radiographics
2000;20:1115-1126

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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 39
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Fluoroscopy Suites
 Portable Fluoroscopy- C Arms
 C-Arm devices with an x-ray
tube placed opposite from the II
 18-cm (7-inch) and 23-cm (9-
inch) and several other field
sizes available
 Operating rooms and ICUs

Schueler, B. A. Radiographics
2000;20:1115-1126
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Take Home Points

 Flat Panel Digital Fluoroscopy is the latest technology being used

 Digital photospot and digital cine available in modern systems
 Different modes of fluoroscopy operation include: continuous, high
dose rate, pulsed, last-frame-hold, road mapping, frame averaging
 Frame averaging used to reduce noise but has more lag
 Automatic brightness control keeps brightness of the image constant
at monitor, adjusts automatically with patient size

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Kalpana M. Kanal, Ph.D., DABR

BME HCMUT 40
 17-Feb-20
Fluoroscopy – Chapter 9 Diagnostic Radiology Imaging Physics
Course
12 -19 October 2006

Take Home Points

 Limiting spatial resolution typically between 4-5 lp/mm

 Temporal resolution is excellent
 Maximum legal EER is 10 R/min in standard mode, 20 R/min in high
dose mode
 Standing 1 m from patient, the fluoroscopist receives 1/1000th of
incident exposure on patient

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BME HCMUT 41