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RTC on RADIATION PROTECTION OF PATIENTS FOR RADIOGRAPHERS Accra, Ghana, July 2011 Image Quality and Patient Dose IAEA 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 IAEA 2 Imaging quality • Efficient diagnosis requires • acceptable noise • good image contrast • sufficient spatial resolution • These factors are linked • “Objective” measurement of quality is difficult IAEA 3 Factors affecting image quality Blur or Unsharpness Contrast Image quality Distortion & artifact IAEA Noise 4 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 IAEA 5 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 • … IAEA • The radiographic contrast plus : • Film characteristics • Screen characteristics • Windowing level of CT and DSA 6 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 IAEA 7 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) IAEA 8 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 IAEA 9 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 IAEA 10 Image Contrast • Difference in signal – pixel value, film density High IAEA Low 11 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 IAEA 12 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) IAEA 13 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 IAEA 14 Factors affecting image sharpness Object Unsharpness Geometric Unsharpness Image Unsharpness Motion Unsharpness IAEA Subject Unsharpness 15 Resolution and Focal Spot Size Penumbra More blur IAEA Appearance of image Less blur 16 Measuring Resolution { Line pair test object One line pair IAEA 17 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 IAEA Large focal spot 18 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 IAEA 19 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 IAEA 20 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 IAEA 21 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) IAEA 22 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) IAEA 23 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 IAEA 24 Noise Decreasing radiation intensity IAEA Increasing noise 25 Contrast & Noise Contrast Noise IAEA 26 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!! IAEA 27 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 IAEA 28 Patient dose assessment IAEA International Atomic Energy Agency Overview • To become familiar with the patient dose assessment and dosimetry instrument characteristics. IAEA 30 Parameters influencing patient exposure IAEA International Atomic Energy Agency Essential parameters influencing patient exposure } Tube voltage Tube current Effective filtration Exposure time Field size IAEA Kerma rate [mGy/min] [min] } Kerma [Gy] [m2] } Area exposure product [Gy m2 ] 32 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 IAEA 33 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 • Patient size • Thickness, volume irradiated…and 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 IAEA 34 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! IAEA 35 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 IAEA 36 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 IAEA 37 Patient dosimetry methods IAEA 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) IAEA 39 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) IAEA 40 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 IAEA 41 Dose measurements: how to measure dose indicators ESD, DAP,CTDI… IAEA International Atomic Energy Agency Measurements of Radiation Output X Ray tube Filter SDD Ion. chamber Table top IAEA Lead slab Phantom (PEP) 43 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 IAEA 44 Measurement of entrance surface dose Includes backscatter (~30%) TLD, solid state dosimeter or ion chamber IAEA 45 Dose Area Product (DAP) Transmission ionization chamber IAEA 46 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 IAEA 2.5*103 Gy 40*10-3 m2 100 Gy m2 47 Calibration of a Dose Area Product (DAP) Ionization chamber Film cassette 10 cm IAEA 10 cm 48 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 IAEA 49 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 IAEA 50 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 IAEA 51 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 IAEA 52 Typical Radiology Doses (Melbourne Data) ESD (mGy) Eff. Dose (mSv) Abdomen (AP) 2.5 0.35 Chest (PA) 0.15 0.023 3.2/4.0 0.23/0.11 Pelvis (AP) 1.7 0.29 Thoracic spine (lat.) 2.6 0.097 Mammography (4 views) 4.4 0.44 Procedure Lumbar spine AP/Lat IAEA 53 XDose IAEA 54 IAEA 55 PCXMC IAEA 56 IAEA 57 ImPACT CT Dose IAEA 58 IAEA 59 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. IAEA 60