Radiography

Acquisition of projectional radiography, with an X-ray generator and a detector

The creation of images by exposing an object to X-rays or other high-energy forms of electromagnetic radiation and capturing the resulting remnant beam (or "shadow") as a latent image is known as "projection radiography". The "shadow" may be converted to light using a fluorescent screen, which is then captured on photographic film, it may be captured by a phosphor screen to be "read" later by a laser (CR), or it may directly activate a matrix of solid-state detectors (DR—similar to a very large version of a CCD in a digital camera). Bone and some organs (such as lungs) especially lend themselves to projection radiography. It is a relatively low-cost investigation with a high diagnostic yield. The difference between soft and hard body parts stems mostly from the fact that carbon has a very low X-ray cross section compared to calcium.

Images generated from computed tomography, including a 3D rendered image at upper left

Computed tomography or CT scan (previously known as CAT scan, the "A" standing for "axial") uses ionizing radiation (x-ray radiation) in conjunction with a computer to create images of both soft and hard tissues. These images look as though the patient was sliced like bread (thus, "tomography" – "tomo" means "slice"). Though CT uses a higher amount of ionizing x-radiation than diagnostic x-rays (both utilising X-ray radiation), with advances in technology, levels of CT radiation dose and scan times have reduced.[1] CT exams are generally short, most lasting only as long as a breath-hold, Contrast agents are also often used, depending on the tissues needing to be seen. Radiographers perform these examinations, sometimes in conjunction with a radiologist (for instance, when a radiologist performs a CT-guided biopsy).

DEXA, or bone densitometry, is used primarily for osteoporosis tests. It is not projection radiography, as the X-rays are emitted in two narrow beams that are scanned across the patient, 90 degrees from each other. Usually the hip (head of the femur), lower back (lumbar spine), or heel (calcaneum) are imaged, and the bone density (amount of calcium) is determined and given a number (a T-score). It is not used for bone imaging, as the image quality is not good enough to make an accurate diagnostic image for fractures, inflammation, etc. It can also be used to measure total body fat, though this is not common. The radiation dose received from DEXA scans is very low, much lower than projection radiography examinations.

Fluoroscopy is a term invented by Thomas Edison during his early X-ray studies. The name refers to the fluorescence he saw while looking at a glowing plate bombarded with X-rays.[2]

The technique provides moving projection radiographs. Fluoroscopy is mainly performed to view movement (of tissue or a contrast agent), or to guide a medical intervention, such as angioplasty, pacemaker insertion, or joint repair/replacement. The last can often be carried out in the operating theatre, using a portable fluoroscopy machine called a C-arm.[3] It can move around the surgery table and make digital images for the surgeon. Biplanar Fluoroscopy works the same as single plane fluoroscopy except displaying two planes at the same time. The ability to work in two planes is important for orthopedic and spinal surgery and can reduce operating times by eliminating re-positioning.[4]

Angiogram showing a transverse projection of the vertebro basilar and posterior cerebral circulation

Angiography is the use of fluoroscopy to view the cardiovascular system. An iodine-based contrast is injected into the bloodstream and watched as it travels around. Since liquid blood and the vessels are not very dense, a contrast with high density (like the large iodine atoms) is used to view the vessels under X-ray. Angiography is used to find aneurysms, leaks, blockages (thromboses), new vessel growth, and placement of catheters and stents. Balloon angioplasty is often done with angiography.

Contrast radiography uses a radiocontrast agent, a type of contrast medium, to make the structures of interest stand out visually from their background. Contrast agents are required in conventional angiography, and can be used in both projectional radiography and computed tomography (called contrast CT).[5][6]

Although not technically radiographic techniques due to not using X-rays, imaging modalities such as PET and MRI are sometimes grouped in radiography because the radiology department of hospitals handle all forms of imaging. Treatment using radiation is known as radiotherapy.

Lead is the most common shield against X-rays because of its high density (11,340 kg/m³), stopping power, ease of installation and low cost. The maximum range of a high-energy photon such as an X-ray in matter is infinite; at every point in the matter traversed by the photon, there is a probability of interaction. Thus there is a very small probability of no interaction over very large distances. The shielding of photon beam is therefore exponential (with an attenuation length being close to the radiation length of the material); doubling the thickness of shielding will square the shielding effect.

Table in this section shows the recommended thickness of lead shielding in function of X-ray energy, from the Recommendations by the Second International Congress of Radiology.[9]

In response to increased concern by the public over radiation doses and the ongoing progress of best practices, The Alliance for Radiation Safety in Pediatric Imaging was formed within the Society for Pediatric Radiology. In concert with the American Society of Radiologic Technologists, the American College of Radiology, and the American Association of Physicists in Medicine, the Society for Pediatric Radiology developed and launched the Image Gently campaign which is designed to maintain high quality imaging studies while using the lowest doses and best radiation safety practices available on pediatric patients.[10] This initiative has been endorsed and applied by a growing list of various professional medical organizations around the world and has received support and assistance from companies that manufacture equipment used in radiology.

Following upon the success of the Image Gently campaign, the American College of Radiology, the Radiological Society of North America, the American Association of Physicists in Medicine, and the American Society of Radiologic Technologists have launched a similar campaign to address this issue in the adult population called Image Wisely.[11] The World Health Organization and International Atomic Energy Agency (IAEA) of the United Nations have also been working in this area and have ongoing projects designed to broaden best practices and lower patient radiation dose.[12][13][14]

Contrary to advice that emphasises only conducting radiographs when in the patient's interest, recent evidence suggests that they are used more frequently when dentists are paid under fee-for-service.[15]

In medicine and dentistry, projectional radiography and computed tomography images generally use X-rays created by X-ray generators, which generate X-rays from X-ray tubes. The resultant images from the radiograph (X-ray generator/machine) or CT scanner are correctly referred to as "radiograms"/"roentgenograms" and "tomograms" respectively.

A number of other sources of X-ray photons are possible, and may be used in industrial radiography or research; these include betatrons, linear accelerators (linacs), and synchrotrons. For gamma rays, radioactive sources such as ¹⁹²Ir, ⁶⁰Co, or ¹³⁷Cs are used.

An anti-scatter grid may be placed between the patient and the detector to reduce the quantity of scattered x-rays that reach the detector. This improves the contrast resolution of the image, but also increases radiation exposure for the patient.[16]

Detectors can be divided into two major categories: imaging detectors (such as photographic plates and X-ray film (photographic film), now mostly replaced by various digitizing devices like image plates or flat panel detectors) and dose measurement devices (such as ionization chambers, Geiger counters, and dosimeters used to measure the local radiation exposure, dose, and/or dose rate, for example, for verifying that radiation protection equipment and procedures are effective on an ongoing basis).[17][18][19]

A radiopaque anatomical side marker is added to each image. For example, if the patient has their right hand x-rayed, the radiographer includes a radiopaque "R" marker within the field of the x-ray beam as an indicator of which hand has been imaged. If a physical marker is not included, the radiographer may add the correct side marker later as part of digital post-processing.[20]

As an alternative to X-ray detectors, image intensifiers are analog devices that readily convert the acquired X-ray image into one visible on a video screen. This device is made of a vacuum tube with a wide input surface coated on the inside with caesium iodide (CsI). When hit by X-rays material phosphors which causes the photocathode adjacent to it to emit electrons. These electron are then focus using electron lenses inside the intensifier to an output screen coated with phosphorescent materials. The image from the output can then be recorded via a camera and displayed.[21]

Digital devices known as array detectors are becoming more common in fluoroscopy. These devices are made of discrete pixelated detectors known as thin-film transistors (TFT) which can either work indirectly by using photo detectors that detect light emitted from a scintillator material such as CsI, or directly by capturing the electrons produced when the X-rays hit the detector. Direct detector do not tend to experience the blurring or spreading effect caused by phosphorescent scintillators of or film screens since the detectors are activated directly by X-ray photons.[22]