CASSETTE-BASED EQUIPMENT ( COMPUTED RADIOGRAPHY)

The phrase digital radiographic image acquisition and processing is being used in
this book to categorize the different ways of acquiring and processing digital
radiographic images. One way to do this is through a cassette-based
system commonly known as computed radiography (CR). Another way is through an
image detector system that is cassette-less and hard-wired to a computer network and
is commonly known as digital radiography (direct or indirect capture; DR). Both systems
use computers to analyze and manipulate the image.
The term radiographic refers to general x-ray procedures as distinct from other digital
modalities such as computed tomography (CT), magnetic resonance imaging (MRI),
and ultrasound (US). This chapter introduces the basic principles of CR and discusses
how CR equipment works. Some similarities between CR and conventional radiography
are discussed. A basic understanding of how CR works prepares you to make sound
ethical decisions when performing radiographic examinations.
Cassette-based or CR systems differ from conventional radiography in that the
cassette is simply a light-proof container that protects an imaging plate from light and
handling. The imaging plate takes the place of radiographic film and is capable of
storing an image formed by incident x-ray photon excitation of phosphors. The reader
releases the stored light and converts it into an electrical signal, which is then digitized.

COMPUTED RADIOGRAPHY EQUIPMENT

Cassette
The CR cassette looks like the conventional radiography cassette. It consists of a
durable, lightweight plastic material. The cassette is backed by a thin sheet of aluminum
that absorbs x-rays. Instead of intensifying screens inside, there is antistatic material
(usually felt) that protects against static electricity buildup, dust collection, and
mechanical damage to the plate.
Imaging Plate
Construction
In CR, the radiographic image is recorded on a thin sheet of plastic known as
the imaging plate. The imaging plate consists of several layers:
 A protective layer. This is a very thin, tough, clear plastic that protects the
phosphor layer.
 A phosphor or active layer. This is a layer of photostimulable phosphor that
“traps” electrons during exposure. It is usually made of phosphors from the
barium fluorohalide family (e.g., barium fluorohalide, chlorohalide, or bromohalide
crystals). This layer may also contain a dye that differentially absorbs the
 stimulating light to prevent as much spread as possible and functions much the
same as dye added to conventional radiographic screens.
 A reflective layer. This is a layer that sends light in a forward direction when
released in the cassette reader. This layer may be black to reduce the spread of
stimulating light and the escape of emitted light. Some detail is lost in this
process.
 A conductive layer. This is a layer of material that absorbs and reduces static
electricity.
 A color layer. Newer plates may contain a color layer, located between the
active layer and the support, that absorbs the stimulating light but reflects emitted
light.
 A support layer. This is a semirigid material that gives the imaging sheet some
strength.
 A backing layer. This is a soft polymer that protects the back of the cassette.

The cassette also contains a window with a barcode label or barcode sticker on the
cassette that allows the technologist to match the image information with the patient-
identifying barcode on the examination request. For each new examination, the
patient-identifying barcode and the barcode label on the cassette must be scanned
and connected to the patient position or examination menu. The cassette will also be
labeled with green or blue stickers indicating the top and left side of the cassette or
with a label on the back of the cassette indicating the top and right sides of the
patient. These stickers serve to orient the cassette to the top of the patient and the
patient’s right side so that the image orientation is in line with the computer
algorithm. This is discussed more in depth in Chapter 7.

Acquiring and Forming the Image

 The patient is x-rayed exactly the same way as in conventional radiography. The
patient is positioned using appropriate positioning techniques, and the cassette is
placed either on the tabletop or within the table Bucky. The patient is then
exposed using the proper combination of kilovolt peak (kVp), milliamperage
seconds (mAs), and distance. The difference lies in how the exposure is
recorded. In CR, the remnant beam interacts with electrons in the barium
fluorohalide crystals contained within the imaging plate. This interaction
stimulates, or gives energy to, electrons in the crystals, allowing them…
to enter the conductive layer, where they are trapped in an area of the crystal
known as the color or phosphor center. This trapped signal will remain for
hours, even days, although deterioration begins almost immediately. In fact, the
trapped signal is never completely lost. That is, a certain amount of exposure
remains trapped so that the imaging plate can never be completely erased.
 However, the residual trapped electrons are so few in number that they do not
interfere with subsequent exposures.
The Reader

 With CR systems, no chemical processor or darkroom is necessary. Instead,

following exposure, the cassette is fed into a reader that removes the imaging
plate and scans it with a laser to release the stored electrons.

The Laser

 A laser, or light amplification of stimulated emission of radiation, is a device that

creates and amplifies a narrow, intense beam of coherent light. The atoms or
molecules of a crystal such as ruby or garnet or of a gas, liquid, or other
substance are excited so that more of them are at high energy levels rather than
low energy levels. Surfaces at both ends of the laser container reflect energy
back and forth as atoms bombard each other, stimulating the lower energy atoms
to emit secondary photons in. the same frequency as the bombarding atoms.
When the energy builds sufficiently, the atoms discharge simultaneously as a
burst of coherent light; it is coherent because all of the photons are traveling in
the same direction at the same frequency. The laser requires a constant power
source to prevent output fluctuations. The laser beam passes through beam-
shaping optics to an optical mirror that directs the laser beam to the surface of
the imaging plate.
Using the Laser to Read the Imaging Plate

 When the cassette is put into the reader, the imaging plate is extracted and
scanned with a helium laser beam or, in more recent systems, solid-state laser
diodes. This beam, about 100 µm wide with a wavelength of 633 nm (or 670 to
690 nm for solid state), scans the plate with red light in a raster pattern and gives
energy to the trapped electrons. The red laser light is emitted at approximately 2
eV, which is necessary to energize the trapped electrons. This extra energy
allows the trapped electrons (Figure 4-10) to escape the active layer where they
emit visible blue light at an energy of 3 eV as they relax into lower energy levels.
As the imaging plate moves through the reader, the laser scans across the
imaging plate multiple times. The plate movement through the scanner is known
as translation because it moves in a parallel manner at a certain rate through
the reader. This scan process produces lines of light intensity information that are
detected by a photomultiplier that amplifies the light and sends it to a digitizer.
The translation speed of the plate must be coordinated with the scan direction of
the laser, or the spacing of the scan lines will be affected. The action of moving
the laser beam across the imaging plate is much like holding a flashlight at the
same height and moving it back and forth across a wall. The more angled the
beam is, the more elliptical the shape of the beam. The same thing happens with
the reader laser beam as it scans.
  This means that if this change in the beam shape were ignored, the output of the
screen would differ from the middle to the edges, resulting in differing spatial
resolution and inconsistent output signals, depending on the position and angle
of the laser beam. To correct this, the beam is “shaped” by special optics that
keep the beam size, shape, and speed largely independent of the beam position.
A beam deflector moves the laser beam rapidly back and forth across the
imaging plate to stimulate the phosphors. Mirrors are used to ensure that the
beam is positioned consistently. Because the type of phosphor material in the
imaging plate has an effect on the amount of energy required, the laser and the
imaging plate should be designed to work together. The light collection optics
direct the released phosphor energy to an optical filter and then to the
photodetector (Figure 4-11).
 Although there will be variances among manufacturers, the typical throughput is
50 cassettes/hr. Some manufacturers claim up to 150 cassettes/hr, but based on
average hospital department workflow, 50/hr is much more realistic.
Digitizing the Signal
 When we talk about digitizing a signal, such as the light signal from the
photomultiplier, we are talking about assigning a numerical value to each light
photon. As humans, we experience the world analogically. We see the world as
infinitely smooth gradients of shape and colors. Analog refers to a device or
system that represents changing values as continuously variable physical
quantities. A typical analog device is a watch: the hands move continuously
around the face and are capable of indicating every possible time of day. In
contrast, a digital clock is capable of representing only a finite number of times
(e.g., every tenth of a second). In the process of digitizing the light signal, each
phosphor storage center is scanned, and the released electrons enter a digitizer
that divides the analog image into squares (matrix) and assigns each square in
the matrix a number based on the brightness of the square. Each square is
called a pixel or picture element. The typical number of pixels in a matrix
ranges from about 512 × 512 to 1024 × 1024 for CT but can be as large as 2500
× 2500 for radiography. The more pixels there...
 are, the greater the image resolution. The image is digitized both by position
(spatial location) and by intensity (gray level). Each pixel contains bits of
information, and the number of bits per pixel that define the shade of each pixel
is known as bit depth. If a pixel has a bit depth of 8, then the number of gray
tones that pixel can produce is 2 to the power of the bit depth, or 2^8 or 256
shades of gray. Therefore how many photons are detected will determine where
it will be located in the matrix in conjunction with the amount of gray level or bit
depth (Figure 4-12). Some CR systems have bit depths of 10 or 12, resulting in
more shades of gray. Each pixel can have a gray level between 0 (0°) and 4096
(2^12). The gray level will be a factor in determining the quality of the image.
Spatial Resolution

 The amount of detail present in any image is known as its spatial resolution.
Just as the crystal size and thickness of the phosphor layer determine resolution
in film/screen radiography, phosphor layer thickness and pixel size determine
resolution in CR. The thinner the phosphor layer, the higher the resolution. In
film/screen radiography, resolution at its best is limited to approximately 10 line
pairs (lp)/mm. In CR, resolution is approximately 2.55 to 51 lp/mm, resulting in
less detail. However, because the dynamic range, or the number of recorded
densities, is much higher, the difference in resolution is more difficult to discern.
More tissue densities on the digital radiograph are seen, giving the appearance
of more detail. For example, an anteroposterior (AP) knee radiograph typically
does not show soft tissue structures on the lateral aspects of the distal femur or
proximal tibia or fibula. An AP knee digital image shows not only the soft tissue
but also the edge of the skin (Figure 4-13). This is because of the wider dynamic
recording range and does not mean there is additional detail. Spatial resolution is
discussed in more detail in Chapter 7.

Speed
In conventional radiography, speed is determined by the size and layers of crystals in
the film and screen. In CR, speed is not exactly the same because there is no
intensifying screen or film. The phosphors emit light according to the width and intensity
of the laser beam as it scans the plate, resulting in a relative “speed” that is roughly
equivalent to a 200 speed film/screen system. CR system “speeds” are a reflection of
the amount of photostimulable luminescence (PSL) given off by the imaging plate
while being scanned by the laser. For example, Fuji Medical Systems (Tokyo, Japan)
reports that a 1-mR exposure at 80 kVp and a source-to-image distance of 72 inches
will result in a luminescence value of 200, hence the “speed” number. In CR, most
cassettes have the same “speed”; however, there are special extremity or chest
cassettes that produce greater resolution. These are typically 100 relative “speed.”
Great care must be taken when converting to a CR system from a film/screen system to
adjust technical factors to reflect the new “speed.” For example, if the technique for a
knee was 20 mAs at 70 kVp in the Bucky with a 400 screen speed system, then the new
CR technique would be 40 mAs at 70 kVp, if the grid ratios are equal. If they are not
equal, then a grid conversion factor is used. More detail about exposure settings for CR
systems is discussed in Chapter 5.
Erasing the Image
The process of reading the image returns most but not all of the electrons to a lower
energy state, effectively removing the image from the plate. However, imaging plates
are extremely sensitive to scatter radiation and should be erased to prevent a buildup of
background signal. The plates should be run at least once a week under an erase cycle
to remove background radiation and scatter. CR readers have an erase mode that
allows the surface of the imaging plate to be scanned without recoding the generated
signal. Systems automatically erase the plate by flooding it with light to remove any
electrons still trapped after the initial plate reading (Figure 4-14). Cassettes should be
erased before using if the last time of erasure is unknown.
Preprocessing, Processing, and Forwarding the Image
Once the imaging plate has been read, the signal is sent to the computer where it is
preprocessed. The data then go to a monitor where the technologist can review the...
SUMMARY
 The cassette-based imaging system has a specially designed cassette made of
durable, lightweight plastic.
 The imaging plate is multilayered with protective, phosphor, reflective,
conductive, color, support, and backing layers.
 Barcodes are used to identify the cassette or imaging plate and examination
request to link the imaging plate with the patient examination.
 Barium fluorohalide crystals in the imaging plate release light energy, which is
then stored in the conductive layer.
 The imaging plate reader uses a laser to scan the imaging plate, releasing the
energy stored in the conductive layer as blue light.
 A photomultiplier amplifies the light and sends it to a signal digitizer.
 The digitizer assigns a numerical value to each pixel in a matrix according to the
brightness of the light and its position.
 Spatial resolution of the digital image is determined by the thickness of the
phosphor layer and the number of pixels, which also affects resolution of the
pixels. Cassette-based spatial resolution is approximately 2.55 to 51 lp/mm
(lower than conventional radiography's 10 lp/mm).
 Because so many more densities are recorded in CR (wide dynamic range),
images appear, but are not, more detailed.
 Because energy stored in the imaging plate dissipates over time, imaging plates
should be read as quickly as possible to avoid losing image information.
 Images are sent to the QC station where they are analyzed and sent to PACS for
long-term storage.
 Imaging plates are erased by exposing them to bright light such as fluorescent
light.
CASSETTELESS EQUIPMENT AND IMAGE ACQUISITION
Digital radiography (DR) imaging is another way to record x-ray exposure after it has
passed through the patient. Whereas digital radiography includes both computed
radiography (CR) and direct or indirect methods of digital image capture, the term DR is
used to describe images recorded on an electronically readable device. Unlike CR, DR
is hard-wired to the image processing system and is cassette-less. In DR detectors, the
materials used for detecting the x-ray signal and the sensors are permanently enclosed
inside a rigid protective housing. Thin-film transistor (TFT) detector arrays may be used
in both direct- and indirect-conversion detectors.
FLAT-PANEL DETECTORS
Flat-panel detectors consist of a photoconductor, amorphous selenium (a-Se), which
holds a charge on its surface that can then be read out by a TFT. This category also
includes silicon and CCD detectors.
Direct Conversion
In direct conversion, x-ray photons are absorbed by the coating material and
immediately converted into an electrical signal. The DR plate has a radiation-conversion
material or photoconductor, typically made of a-Se. This material absorbs x-rays and
converts them to electrons, which are stored in the TFT detectors (Figure 6-1).
The thin-film transistor (TFT) is a photosensitive array made up of small (about 100 to
200 µm) pixels. Each pixel contains a photodiode that absorbs the electrons and
generates electrical charges. A field-effect transistor (FET) or silicon TFT isolates
each pixel element and reacts like a switch to send the electrical charges to the image
processor (Figure 6-2). More than 1 million pixels can be read and converted to a
composite digital image in less than 1 second. A line of TFT switches, each associated...
with a storage capacitor, allows the electric charge information to discharge when the
switches are closed. The information is discharged onto the data columns and read out
with dedicated electronics. Specialized silicon integrated circuits are connected along
the edges of the detector matrix. On one side, integrated circuits control the line
scanning sequence, and on the other side, low-noise, high-sensitivity amplifiers perform
the readout, amplification, and analog-to-digital conversion. High-speed digital
electronics are then used to achieve fast image acquisition and processing.
Indirect Conversion
Indirect-conversion detectors are similar to direct detectors in that they use TFT
technology. Unlike direct conversion, indirect conversion is a two-step process: x-ray
photons are converted to light, and then the light photons are converted to an electrical
signal. A scintillator converts x-rays into visible light. That light is then converted into
an electric charge by photodetectors such as amorphous silicon photodiode arrays or
array-coupled devices (CCDs). X-ray photons striking the dielectric receptor are
absorbed by a scintillation layer in the imaging plate that converts the incident x-ray
photon energy to light. A photosensitive array, made up of small (about 100 to 200 µm)
pixels, converts the light into electrical charges. Each pixel contains a photodiode that
absorbs the light from the scintillator and generates electrical charges. A FET or silicon
TFT isolates each pixel element and reacts like a switch to send the electrical charges
to the image processor. As with direct conversion, more than 1 million pixels can be
read and converted to a composite digital image in less than 1 second (Figure 6-3).

Amorphous Silicon Detector

This type of flat-panel sensor uses thin films of silicon integrated with arrays of
photodiodes. These photodiodes are coated with a crystalline cesium iodide
(CsI) scintillator or a rare-earth scintillator (terbium-doped gadolinium dioxide sulfide).
When these scintillators are struck by x-rays, visible light is emitted proportionate to the
incident x-ray energy. The light photons are then converted into an electric charge by
the photodiode arrays. Unlike the selenium-based system used for direct conversion,
this type of indirect-conversion detector technology requires a two-step process for x-
ray detection. The scintillator converts the x-ray beams into visible light, and light is then
converted into an electric charge by photodetectors, such as amorphous silicon
photodiodes.
CsI Detectors
A newer type of amorphous silicon detector uses a CsI scintillator. The scintillator is
made by growing very thin crystalline needles (5 µm wide) that work as light-directing
tubes, much like fiberoptics (Figure 6-4). This allows greater detection of x-rays, and
because there is almost no light spread, there is much greater resolution. These
needles absorb the x-ray photons and convert their energy into light, channeling it to the
amorphous silicon photodiode array. As the light hits the array, the charge on each of
the photodiodes decreases in proportion to the light received. Each photodiode
represents a pixel, and the amount of charge required to recharge each photodiode is
read electronically and converted to digital data. This process is very low-noise and very
fast (approximately 30 million pixels/sec).
Charge-Coupled Devices
The oldest indirect-conversion DR system is based on charge-coupled devices
(CCDs). X-ray photons interact with a scintillation material, such as photosensitive
phosphors, and this signal is coupled, or linked, by lenses or fiberoptics that act like
cameras. These cameras reduce the size of the projected visible light image and
transfer the image to one or more small (2 to 4 cm²) CCDs that convert the light into an
electrical charge. This charge is stored in a sequential pattern and released line by line
and sent to an analog-digital converter. Even though CCD-based detectors require
optical coupling and image size reduction, they are both widely available and relatively
low cost (Figure 6-5).
COMPLEMENTARY METAL OXIDE SILICON
Developed by NASA, complementary metal oxide silicon (CMOS) systems use
specialized pixel sensors that, when struck with x-ray photons, convert the x-rays into
light photons and store them in capacitors. Each pixel has its own amplifier, which is
switched on and off by circuitry within the pixel, converting the light photons into
electrical charges. Voltage from the amplifier is converted by an analog-to-digital
converter also located within the pixel. This system is highly efficient and takes up less
fill space than CCDs.
DETECTIVE QUANTUM EFFICIENCY
How efficiently a system converts the x-ray input signal into a useful output image is
known as detective quantum efficiency (DQE). DQE is a measurement of the
percentage of x-rays that is absorbed when they hit the detector. The linear, wide-
latitude input/output characteristic of CR systems relative to screen/film systems leads
to a wider DQE latitude for CR, which implies that CR has the ability to convert incoming
x-rays into “useful” output over a much wider range of exposure than can be
accommodated with screen/film systems. In other words, CR records all of the phosphor
output. Systems with higher quantum efficiency can produce higher quality images at
lower dose.
Both indirect and direct DR capture technology has increased DQE over CR. However,
DR direct capture technology, because it does not have the light conversion step and
consequently no light spread, increases DQE the most. There is no light to blur the
recorded signal output; less dose is required than for CR; and higher quality images are
produced. Newer CMOS indirect DR capture systems may be equal to direct image
acquisition because of the crystal light tubes, which also prevent light spread.
The DQE of detectors changes with kilovoltage peak (kVp), but generally the DQE of
selenium- and phosphor-based systems is higher than for CR, CCD, and CMOS
systems. CCD in particular has problems with low light capture.
The area of a TFT array is limited because of the structure of the matrix. This also
affects the size and number of pixels available. Known as the fill factor, the larger the
area of the TFT photodiodes, the more radiation can be detected and the greater
amount of signal generated. Consequently, the greater the area of the TFT array, the
higher the DQE.
DETECTOR SIZE
Detector size is critical. Detectors must be large enough to cover the entire area to be
imaged and small enough to be practical. For chest x-rays, the detector needs to
SPATIAL RESOLUTION
Depending on the detector’s physical characteristics, spatial resolution can vary a great
deal. Spatial resolution of a-Se for direct detectors and CsI for indirect detectors is
higher than CR detectors but lower than film/screen radiography. Excessive image
processing, in an effort to alter image sharpness, can lead to excessive noise. Digital
images can be processed to alter apparent image sharpness; however, excessive
processing can lead to an increase in perceived noise. The best resolution will be
achieved by using the appropriate technical factors and materials.
PIXEL SIZE AND MATRIX SIZE
The amount of resolution in an image is determined by the size of the pixels and the
spacing between them, or pixel pitch. More pixels do not always mean better resolution
because of the amount of x-ray scatter, light scatter, or both within the receptor. Larger
matrices combined with small pixel size will increase resolution, but it may not be
practical to use large matrices. The larger the matrix, the larger the size of the image,
and the greater the space needed for network transmission and picture archival and
communication system (PACS) storage. Typically, 2000 pixels/row are adequate for
most diagnostic examinations. Smaller pixel sizes may be necessary for mammographic
examinations. Pixel size in TFT displays is related to the design of the capacitance
elements and also to the fill factor of these devices.
TECHNICAL FACTOR AND EQUIPMENT SELECTION
Selection of kVp, milliamperage seconds (mAs), distance, collimation, and anatomic
markers is the same for cassette-less systems as it is for cassette-based systems.
Typically, only one exposure is made at a time on the image receptor, but that does not
mean that collimation is unnecessary. In fact, collimation may be more critical because
the cassette-less systems are more sensitive to scatter radiation. When grids are used
in any digital imaging system, there is always the possibility that the grid lines will
interfere with the pixel rows, resulting in the moiré pattern error. Grid interaction artifacts
are not always easy to identify and can decrease image quality, so caution and proper
selection of the grid are advised.
POTENTIAL CASSETTELESS IMAGE ACQUISITION ERRORS
Although the conversion of x-rays to a digital signal occurs very quickly, each step of the
conversion has the potential of signal loss. The major cause of noise in this system
is electronic noise, and this is the main factor limiting quality. The more time allowed
for signal conversion, the more precise the pixel values. Incomplete charge transfer will
cause inaccuracies in pixel values in subsequent exposures, reducing image quality.
Additionally, if exposures are taken in too rapid sequences, there may not be enough
time for each previous exposure to transfer the entire signal, resulting in what is known
as electronic memory artifact. The detector readout may have built-in safeguards
against this, but it would be wise to know whether these protective measures are in
place. Not all cassette-less systems are appropriate for high-speed, rapid succession
imaging such as fluoroscopy.
SUMMARY
 There are two types of caseless digital imaging systems: direct and indirect.
 Direct sensors are TFT arrays of amorphous silicon coated with a-Se.
 Direct sensors absorb x-ray photons and immediately convert them to an
electrical signal.
 Indirect conversion detectors use a scintillator that converts x-rays into visible
light, which is then converted into an electric charge.
 CCDs act as miniature cameras that convert light produced by x-ray interaction
with photostimulable phosphors into an electrical charge.
 Pixel and matrix size are important both in determining the amount of resolution
and the size of the image to be stored in the PACS system. In TFT technology,
both pixel and matrix size are determined by the amount of area available to “fill”
with photons.
 Technical and equipment factors in casetteless systems are equivalent to
cassette-based systems but may be more critical in terms of grid use and
collimation.
 Incomplete transfer of the signal generated in the casetteless receptor or the
amount of signal retained by the receptor can cause artifacts, especially with
short acquisition or rapid succession acquisitions.