Chapter 1: Digital Radiography: An Overview

Introduction

Film-screen radiographic imaging has been the workhorse of radiology ever since the discovery of X-ray
by WC Roentgen in 1895. Today film-screen radiography is now obsolete and has been replaced by
digital radiographic imaging or simply digital radiography.

Digital radiography technologies include not only digital image acquisition modalities but also digital
image processing, display, storage, and image communication. Specifically, digital image acquisition
modalities include computed radiography, flat-panel digital radiography, digital mammography, and
digital fluoroscopy for routine gastrointestinal fluoroscopy and vascular imaging.

Furthermore, the other technologies of image processing, display, storage, and image communication
using computers fall within the domain of information technology. The application of information
technology to digital radiography has created an area of study and practice popularly referred to as
medical imaging informatics.

The next era in medical imaging informatics includes at least six major topics that have received
increasing attention in the literature, and which are important for all those working in medical imaging
and radiation sciences. These include enterprise imaging, Big Data, cloud computing, machine learning
and deep learning, and artificial intelligence.

Digital Radiography: A Definition

The American Association of Physicists in Medicine (AAPM) has offered a definition of digital
radiography as “radiographic imaging technology producing digital projection images such as those
using:

- photostimulable storage phosphor (computed radiography, or CR)

These technologies can produce acceptable image quality over a wider range of exposure techniques
compared to film-screen radiography.

Digital detectors capture and convert X-ray attenuation data from the patient into electronic signals
(analog signals) that are subsequently converted into digital data for processing by a digital computer.
The result of processing is a digital image that must be converted into one that can be displayed on a
computer monitor for viewing by an observer.
The major system components and the essential steps to digital image production are displayed image,
can be manipulated using a variety of digital image processing techniques to enhance the interpretation
of diagnostic radiology images.

Film-Based Radiography: A Brief Review

Basic Steps in the Production of a Radiograph

The production of a film-based radiographic image involves several steps, X-rays pass through the
patient and fall upon the film to form a latent image. The latent image is then rendered visible using
chemical processing and subsequently displayed on a light view box for viewing and interpretation by a
radiologist.
The film image appears with varying degrees of blackening as a result of the amount of exposure
transmitted by different parts of the anatomy. While more exposure produces more blackening, less
exposure produces less blackening.

Additionally, while the blackening is referred to as the film density, the difference in densities in the
image is referred to as the film contrast. The film therefore converts the radiation transmitted by the
various types of tissues (tissue contrast) into film contrast.

An image displayed on a light view box transmits light into the eyes of the radiologist who interprets the
image. This transmitted light can be measured using a densitometer and is referred to as the optical
density (OD), which is defined as the log of the ratio of the intensity of the view box (original intensity)
to the intensity of the transmitted light. The OD is used to describe the degree of film blackening as a
result of radiation exposure.

The Film Characteristic Curve

The film contrast can be described by what is popularly known as the film characteristic curve or the
Hurter-Driffield (H and D) curve. The curve is a plot of the optical density (OD) to the radiation exposure
(or more accurately, the logarithm of the relative exposure) used in the imaging process. The purpose of
the curve is to indicate the degree of contrast or different densities that a film can display using a range
of exposures.

An idealized characteristic curve for film-screen radiography, has three main segments:
- the toe
- the slope (straight line portion)
- the shoulder
While the toe and shoulder indicate underexposure and overexposure, respectively, the slope
represents the useful portion of the curve and reflects acceptable exposure or the range of useful
densities.

This simply means that if an exposure falls at the toe region (OD = 0.12–0.20), the image will be light and
generally useless. If the exposure falls in the shoulder region of the curve (OD = about 3.2), the image
will be black and serve no useful purpose in providing a diagnosis. If the exposure falls within the slope
of the curve (OD = 0.3–2.2), the image contrast (density) will be acceptable, and this region of the curve
contains the useful range of exposures.

There are four other factors that can be described using the characteristic curve. These include:
- Film Speed
- Average Gradient
- Film Gamma
- Film Latitude

The film speed - refers to the sensitivity of the film to radiation, and it is inversely proportional to the
exposure (E) and can be expressed algebraically as:

Film speed = 1/ E

This means that films with high speeds (fast films) require less exposure than films with low speeds
(slow films). The film latitude on the other hand describes the range of exposures that would produce
useful densities (contrast).

While wide exposure latitude films can respond to a wide range of exposures, films with narrow
exposure latitude can respond only to a small range of exposures.

In the latter situation, the technologist has to be very precise in the selection of the exposure technique
factors for the anatomical part under investigation. This is mainly because the film emulsion has a
nonlinear response to chemical processing.
Exposure Technique Factors

Exposure technique factors affect the quantity and quality of the X-ray beam coming from the X-ray
tube during the examination.

These factors are set by the technologist on the console and are specifically selected for the patient size
and type of examination and include:

- Kilovolt Peak (kVp)

kV - controls the X-ray beam quality or the penetrating power of the X-ray beam.

mA - controls the X-ray beam quantity that is the number of photons in the beam.

Exposure time - on the other hand determines the length of time that the X-ray beam is on during the
exposure to the patient.

The combination of mA and s results in the mAs which controls the X-ray beam quantity, in the same
manner as mA and s used separately.

Exposure technique factors affect the contrast and density of the images on film.

Automatic Exposure Control

The use of manual selection of exposure technique factors sometimes results in poor exposures that
ultimately affected the image on the film.

The problem is solved with the use of automatic exposure control (AEC) in which a preset quantity of
radiation reaching the film image detector (cassette) is automatically measured and terminated when a
preset optical density (degree of blackening, in the case of film) or signal-to-noise ratio (SNR) in the case
of a digital detector is reached.

Image Quality Factors

The overall goal of radiographic imaging is to produce optimum image quality. The characteristics of a
film that determine its quality are:

- resolution
- contrast
- noise
- distortion
- artifacts

Resolution - refers to a characteristic that allows an observer to see separate objects on a film. There
are two types of resolution, spatial resolution and contrast resolution.

Resolution - refers to detail or sharpness (or visibility of detail), the latter refers to the differences in
tissue contrast that can be seen on the film.
Spatial resolution - refers to detail, and it is measured in line pairs per millimeter (lp/mm).

The greater the lp/mm a film can demonstrate, the greater the detail that can be seen.

Detail is affected by several factors such as:

- Focal Spot Size

Detail is optimum when small focal spots are used, when the patient does not move during the
exposure, and when detail cassettes are used.

Contrast - is a significant image quality characteristic. It is the density differences on a radio graphic
image.

A high-contrast image is characterized by regions of high density (dark) and low density (light).

Several factors affect the contrast of a radiographic image, including:

- Object
- Energy of the beam
- Scattered radiation
- Grids
- Film

The main controlling factor for image contrast, however, is kVp. Optimum contrast is produced when
low kVp techniques are used. A grid improves radiographic contrast by absorbing scattered radiation
before it gets to the film.

Noise - on an image appears as mottle, and the image has a grainy appearance (quantum mottle).

This occurs when few photons are used to create an image on the X-ray film, since the main con trolling
factor for the number of photons from the X-ray tube is mAs.

Low mAs will result in more noise compared to high mAs techniques.

Furthermore, there are other factors that affect noise such as the kVp.

Less noise is produced when higher kVp techniques are used for the same mA settings. The technologist
must therefore select the best possible factors in order to produce optimum image quality.
Radiation Dose Considerations

The radiation dose in film-screen radiography is affected by several factors including:

- Exposure Technique Factors

While the dose is directly proportional to the mAs, meaning that if the mAs is doubled, the dose is
doubled, it (dose) is proportional to the square of the change of the kVp. Higher kVp techniques will
result in less absorbed dose in the patient.

Limitations of Film-Screen Radiography

Film-based radiography has been the workhorse of radiology ever since the discovery of X-rays in 1895,
and despite the successful use for over 100 years and its present use in many departments today, one
of the major problems with the radiographic imaging process is poor image quality if the initial radiation
exposure has not been accurately determined.