Brian Requires an X-ray

David: Throughout this course we follow the case of Brian, who is a 29 year old male
who presented to me after a blackout. Brian's problems appear to have started a year ago
when he was involved in a serious motor vehicle accident. To understand what
happened to Brian we are going to go back a year and hear from a junior doctor in the
Accident and Emergency Department.
A&E Doctor: Well, in Bay 4 we've got a 26 year old male, Brian, who was brought in
by ambulance about an hour ago. Witnesses reported that they saw Brian's car run a red
light and did get hit on the right hand side. By the time the ambulance guys arrived the
other motorists had already pulled him out of the car. The ambulance guys did say that
was wearing his seat belt, so that's good. When we examined him in the emergency
department a short time ago we could see some early signs of bruising on his right thigh
and of course bruising and swelling over his right shoulder and upper arm and over his
chest related to the seatbelt. He's in quite a bit of pain, mainly just in his right arm
which is sore to touch. His blood pressure is pretty good - about 150/90.
Exam is normal apart from his arm; just abdomen is soft and his lungs and his heart
check out fine. No signs on neurological examination. So we're just going to give him
some painkillers and we are sending him off for an X-ray of his arm and his chest. So I
think it will turn out that we are dealing with a fracture of the arm but not to be
concerned about any internal injuries at this stage. So you can see here he does have an
obvious fracture in the upper part of the the large bone in his arm -- called the humerus.
I dare say we'll send to the orthopaedic ward for surgery and we will have to get a plate
in that bone just later today. And all going well I think we'll be able to send him home
in a couple of days.

Introduction to Basic Scientific Principles of X-rays

In this sub-section, you will be introduced to the physics of radiation, the

energy of different types of radiation, the biological effects of high-energy
radiation (such as used in X-rays), and the safety requirements of acquiring
X-ray images.

Table of Contents for this sub-section:

Please navigate using the horizontal menu.

Electromagnetic Radiation

Energy as a function of wavelength

Introduction to radiobiology

Aim for minimal exposure

Quiz

Electromagnetic Radiation
 Hello everyone. In this video we will cover electromagnetic radiation, and why it is the
basis of many of the imaging technologies that you will encounter in this course.
It is part of our everyday life, because visible light, infra-red and ultra-violet light and
radio waves, as well as X-rays and gamma-rays, are all types of electromagnetic
radiation.
So, what is electromagnetic radiation?
It consists of two perpendicular fields: an electric field and a magnetic field.
The two fields are sinusoidal and in phase, which means that as they oscillate, they both
pass through zero at the same point in time. The energy moves or propagates in the
direction k, which is perpendicular to the two oscillating fields. The wavelength is the
distance required to complete one full cycle of the wave, and we call this lambda, and
this is the Greek symbol for lambda.
Electromagnetic radiation has an important property: it is self-propagating. Simply put,
the oscillating magnetic field produces an oscillating electric field, and the oscillating
electric field produces an oscillating magnetic field. This means, that it doesn't need the
source to continue to add energy, unlike other forms of EM Fields, such as magnetic
fields or static electricity. These only occur close to the source. On the contrary, once
electromagnetic radiation has been produced, the transmitter can no longer influence it,
and it will continue to move in a straight line unless it encounters something that can
slow it down, stop it, or absorb it.
Today, we take for granted that light and other forms of electromagnetic radiation carry
energy, but let us look at the history of the science surrounding EM radiation in just
over 150 years. In 1865, Maxwell published "A Dynamical Theory of the
Electromagnetic Field". He discovered that light is a wave. In 1900, Max Planck
proposed that the energy in light could only be emitted or absorbed in discrete amounts.
That is the energy of light is quantized. It is not done in random amounts. This was the
beginning of what we now call Quantum Theory. Importantly, Planck also recognised
that the energy was related to the frequency of the light. Until then it was thought that it
was the intensity of the light that determined how it interacted with matter. Planck's
equation defines that relationship whereby the energy is directly proportional to the
frequency, and the proportionality constant, h, is now called Planck's constant.
In 1905, Einstein went a step further by stating that light has mass and momentum, and
demonstrated it through the Photoelectric effect, whereby light could displace an
electron and cause a current to flow. He postulated that light consisted of particles, just
like electrons. In 1923, Compton showed that light could be scattered by an electron,
demonstrating that light indeed travelled as a particle. The importance of this is
demonstrated by the Nobel Prizes. Maxwell himself was too early, but is often described
as the third most influential physicist of all time. In 1919 Max Planck received the
Nobel Prize for the theory that light is quantized. 1921 Einstein received the Nobel
Prize for the Photoelectric effect in which he explained the interaction between photons
and electrons. Then in 1927 Compton received the Nobel Prize for demonstrating that
light could be scattered by hitting an electron.
You will note the length of time that passed between discovery and the recognition for
Planck and Einstein. These ideas contradicted everything that had been taught in
classical physics. But by the time Compton came along, the wave-particle theory of
light was widely accepted, and it was only 4 years before he was acknowledged with his
Nobel Prize. Let us now consider some of the important properties of electromagnetic
radiation. It moves at a speed that we all know of as the speed of light, which has the
symbol c. In a vacuum this is 300 million or 3 x 10^8 meters per second. Some of you
may have learnt 186,000 miles per second, but in the course we will use SI units, which
are based on metric units. We will also use shorthand nomenclature, such as 3e8 metres
second to the -1. This means exactly the same thing. When electromagnetic radiation
moves into transparent materials it slows down. This is important, because this results in
refraction, which causes the radiation to bend.
The degree to which it slows down is dependent on the frequency, and it is very
sensitive. We have all observed the diffraction of light by a prism, or even a rainbow.
EM radiation can also interact with the electrons and the nuclei in a material, to cause it
to be absorbed. This energy can be transferred to the electron or the nucleus, or
converted to another form of energy, such as heat. We will discover later that
transparency and absorption are functions of frequency (or alternatively, the energy of
the photons), and so something that is not transparent to visible light, may be
transparent to EM radiation at a higher frequency, such as X-rays.
The speed of any wave is the product of its frequency and wavelength. For EM
radiation, the equation becomes c equals nu times lambda. Alternatively we can say that
frequency is inversely proportional to wavelength. This means that as the frequency gets
higher, the wavelength gets shorter. In the next exercise, you will investigate further the
relationship between frequency and wavelength.

Simulation: Energy as a function of wavelength

You should note that according to the Planck equation, as frequency

increases, the energy also increases, and the wavelength decreases.
Remember that frequency and wavelength are related by the speed of light.

The energy in the box is expressed in Joules, which is the International

System (SI) of unit for energy, and is now the universally accepted unit in
scientific literature. But we have included an older scale, the electron volt
along the bottom of the graph, as this is still widely used in X-ray
documentation.

Also look at the units for wavelength and frequency. The SI units are metre
and Hertz, but we have included the standard subunits of pico, nano, micro,
kilo, mega, giga, tera.

Introduction to Radiobiology

X-rays belong to a class of radiation called ionising. This means that they
can interact with atoms and molecules and change their structure and
function. They do this because they have enough energy to knock an
electron out of the atom. The consequence of this is that an atom or
molecule that was neutral now has a positive charge. It becomes an ion.
Ions behave very differently to neutral molecules, largely because they
become soluble in water and more reactive.

In biological systems, such changes can result in mutations (through alteration of

DNA), which can cause radiation sickness, cancer or death. The reasons for this is
beyond this course, but, in summary, if the DNA is altered, cells will either be prevented
from multiplying, or multiplication can get out of control, by preventing or slowing
apoptosis, or the new cells will be deformed in some way, such that their function is
disrupted. Even sunburn, caused by UV radiation, belongs to this class. X-rays are
photons with much higher energy than UV, and so the effects are potentially
considerably greater.

The role of the doctor, together with the radiographer is to minimise the risk to the
patient. This takes two forms:

i) Risk-benefit analysis: Does the diagnostic benefit outweigh the potential risk
of doing further harm? If the potential information is going to improve the patients
quality of life, or preserve life, then is the procedure worth pursuing, despite the risk? In
making this assessment, the clinician will also consider alternative methods of getting
the same information. Investigative surgery is an option, but the risks of the anaesthetic
and surgical procedure is probably greater than the risk of the X-ray.

ii) Minimise the exposure: The radiographer is the person who takes the X-rays.
They need to set up the X-ray system to use the minimum exposure to X-rays, to
achieve images of sufficient quality to give reliable diagnostic information.

In considering ionising radiation, there are two classes or categories of effect: Stochastic
and Determinate.

Stochastic (or probabilistic effects): This is when the probability of having an effect is
dependent on the dose. The more X-rays that you have, the higher the risk of damage. In
considering this, physicians need to consider the total dose that a person receives over a
longer period of time. This is why the number of high exposure X-rays needs to be
limited. Thus, it is no longer common practice for patients to get dental X-rays with
every visit to the dentist. Similarly, X-rays are no longer used to check that a child has
the correct sized shoes.

Deterministic: These are effects that are dependent on the intensity of the dose. This is
a combination of the energy of the photons and the number reaching a particular cell in
a short period of time. The radiographer needs to optimise the parameters. Later in the
course we will consider the interaction between kVp, which defines the energy of the
photons and mAs, which controls the flux of photons.

Aim for Minimal Exposure

Patient: You will also realise that the exposure to the patient needs to be
minimised. Some organs are more susceptible to damage, in particular the
gonads, as these contain the heritable information that will be transferred to
later generations. The X-ray gantry will be minimised to reduce exposure to
that region of the body. If it is not possible to completely avoid X-ray
exposure, the radiographer will position lead aprons or shields, to protect
the patient.

The radiographer will also ensure that the minimum area possible is
exposed to X-rays. This is done by changing shutters in the X-ray gantry.
This is called coning. In the following activity, you can adjust the shutters
and see how the X-ray exposure is decreased.
Introduction to X-ray technology and Table of content

In this sub-section, we will investigate the production of X-rays, how they are
used to produce images, and the technology used to safely produce those
images.

Table of Contents for this sub-section:

Please navigate using the horizontal menu.

X-ray tubes

X-ray room

Grid and Collimation

Fluorescence

Image Intensifier

Quiz

X-ray Tubes

Welcome back. In this session we're going to look at the core of the X-ray system: the
source of the X-rays, the X-ray tube. X-rays are emitted when a high-speed electron hits
a metal target. Only 1 % of the energy in the electron beam is converted to photons.

The rest is converted to heat. So producing heat inside a vacuum is a problem, because
it is hard to get rid of it. A large anode can be used to absorb the heat, but this relies on
conduction. If the conduction is not rapid enough, the anode will start to melt. So to
increase the capacity, the anode is rotated. A new surface is continually exposed to the
electron beam. By the time the anode rotates through 360 degrees, that spot of the anode
has had a chance to cool down. So let us start by having a look at a real X-ray tube. This
is the glass tube, which must contain a high vacuum. Otherwise, the electrons will
collide with molecules of air, loosing energy. At this end here, we have a hot wire
cathode.

The thermionic process results in the release of the electrons, which are accelerated
towards the anode, which is between 30 and 100 kV relative to the cathode. When the
electron hits the anode, it is decelerated as it collides with electrons in the metal. As it
decelerates, it looses energy which is released as an X-ray. The angle on the anode
directs the X-ray beam towards this window. Here we have at this end, the motor which
rotates the anode.
Let us now go to a diagrammatic depiction of the rotating anode X-ray tube. The
cathode is heated to cause the release of electrons. These are accelerated by a high
voltage towards the anode. Which is positively charged relative to the cathode. This
whole process needs to be conducted within a high vacuum. Otherwise the electrons
will strike air molecules, and thereby lose their energy before they reach the anode.
When the high energy electrons strike the anode, they release energy. Some of the
energy is released as X-rays, but most is converted to heat. To prevent the anode from
melting, it is continuously rotating. And so the hot spot moves away from the electron
beam. It then has time to cool down, before it gets back to the position in the beam of
the electrons.

X-ray Room

Hi, welcome back. We've spent a lot of time looking at the theory behind X-rays, now
let's actually go into an X-ray room and look at the equipment. We will start with an X-
ray table, where the patient is lying on a moveable "floating top" table, with the X-ray
tube above, and the detector system/cassette in the bed, under the patient. The unit
containing the X-ray tube can be moved to give the correct positioning over the bed.
Modern systems are very flexible, and this one can be moved to the end of the bed, for
imaging a wrist, with the patient sitting on a chair. Under the bed is the detector system.
This can be either photographic film or a digital detector, as is used in this particular
system. The bed also contains the Bucky grid. If you remember, a grid is used to reduce
the scatter X-rays.
It needs to be moving slightly backwards and forwards during the X-ray exposure,
otherwise there will be lines from the grid on the image. The next item to consider is
the X-ray tube. It is contained within this unit. If you remember back to the lesson on X-
ray tubes, we learned that they produce a lot of heat, so there is a cooling system, which
is the purpose of these hoses. Below the X-ray tube but still within this unit is the light
beam diaphragm (the LBD) which is used for collimation. Let us now look at how the
radiographer will use the light beam diaphragm to collimate or restrict the X-ray beam
to the desired region, in this case a lumber spine X-ray. A light in the unit simulates
where the X-ray beam will fall, and the radiographer will feel for anatomical landmarks
to center the patient to the correct position. The light beam diaphragm is then
adjusted to a narrow section, extending from the ribs to the pelvis. A laser is used to
ensure that the center of the desired field of view is exactly aligned with the center of
the detector system. The radiographer can then retreat behind an X-ray shield containing
lead, to operate the X-ray exposure. In most cases, it takes less than a second for each
exposure.

X-Ray Grid
Next you will learn about X-ray grids. You can cycle through this set of diagrams below
which explains why we need them, and how they work.
Let's start with why grids are necessary. You will recall that X-rays can be
absorbed or deflected. If they are scattered at different angles, then the
position that they strike the capture device will be random. The black lines
are the non-deflected or primary X-rays that produce the desired image. The
blue lines are the deflected or scattered X-rays, and the blue image is the
unwanted image. This is noise in the image.

Let us now look at that, with more X-rays. Now the blue image, produced by
the scattered X-rays, is obscuring or blurring most of the real image.
A grid is a type of filter with alternating strips that are transparent and
opaque to X-rays. Because of the thickness of the grid, only the X-rays that
are aligned with the grid will pass through. The problem with this grid, is
that the slots between the strips are parallel, whereas the X-rays are coming
from a point source. As we move away from the centre, the primary X-rays
are also blocked.

The advance on the parallel grid is the focussed grid, where the angle of the
slots changes, to allow for the angle of the incident X-rays, and therefore the
primary X-rays. Now, we can see that more of the primary X-rays pass
through, but the scattered X-rays are filtered. However, there is still a
problem. In these drawings, for clarity, we have exaggerated the grid, by
using equal widths of transparent and opaque strip, and so half of the
primary X-rays are blocked. But even when the transparent strips are much
wider, the grid will always cast a shadow, producing lines on the image.
See what happens when the grid is moved backwards and forwards. Now, all
parts of the film are exposed by equal numbers of primary X-rays, and all
the scatter X-rays are blocked.

FLUORESCENCE
Early detection of X-rays was through fluorescence. This is a process that occurs in
much of nature as well as the laboratory. Electromagnetic (EM) radiation of one
frequency strikes an object, and EM radiation of another frequency is emitted. So, for
example X-rays will strike a screen and visible light is emitted. We no longer use
fluorescence screens directly, although later on you will see how they form a critical
component of X-ray intensifiers.

The animation below shows what happens at the level of the atoms in the fluorescent
object, be it a screen or a fluorescent algae.

A photon is absorbed by an atom, and the electrons are excited and move to a higher
energy shell. The frequency of the photon will dictate the energy, and therefore how
many levels the electron can jump. The electrons then lose energy, usually as heat, and
cascade back down one or more levels. Finally the electron makes a large jump, down,
and releases a photon at a lower frequency, also dictated by the amount of energy that is
being lost by the electron in that final jump.

IMAGE INTENSIFIER

Early X-rays were produced either by direct exposure of the film by X-rays or
by viewing a phosphorescent screen.
Both these methods have been replaced by the image intensifier, which
converts the low intensity X-rays to visible light, which can be used to
expose film, or captured electronically.

The animation below describes the basic principles of the X-ray image
intensifier.

This animation demonstrates the principles by which all X-ray image intensifiers
operate. The X-rays arrive at the input window, where they are converted to a stream of
electrons which can be accelerated towards the anode by a high voltage, and focused by
electrodes positioned along the path. At the anode they strike a phosphorus screen, and
are converted to light, which is captured by film or CCD camera. Let us now look more
closely at the input stage. Here we see the X-rays entering the scintillator cells, in this
case cesium iodide, where they are converted to photons at the frequency of visible
light. These photons strike the photocathode, causing electrons to be released. The
benefit of the image intensifier is that the signal intensity of the X-ray beam can be
amplified through the selection of scintillator, magnitude of the high voltage, and the
nature of the focusing components.

Which control the electron stream, and then the sensitivity of the phosphorus screen,
and of the image capture device, which are now operating at visible light frequencies.

Introduction to contrast

By now, you should have learnt that X-rays are attenuated by the density of
the tissue, and you probably realise from having seen X-rays, that bones,
which are dense, stop the most X-rays, and so are very obvious on the
image. We normally view most images as a negative, which means that the
part of the film receiving no X-rays is bright.

You will recall that attenuation refers to the degree to which the number of
X-rays reaching the film is reduced. Contrast refers to the ability, in the
image, to differentiate different structures.

In this sub-section, we will look at the way in which the contrast can be
controlled by the instrumentation, and how we can change the contrast,
through the use of contrast agents.

Table of content:

Image density and contrast

Radiopaque dye

Contrast agent and fluoroscopy

 Fluoroscopy

Image identifier

Quiz

Image density and contrast

The quality of X-ray images is determined by a combination of sufficient

density and appropriate contrast. This can be considered analogous to
brightness and contrast on your television or computer monitor.

The radiographer/technologist needs to adjust the settings in accordance

with the thickness of the structure, and the desired level of detail. In
adjusting these settings, the radiographer must observe the need for
minimum exposure to meet the safety requirements of the investigation

In the simulation below, you can observe how these three parameters can
be manipulated.

1. mA is the current in the hot-filament cathode

2. S is the time that the X-ray tube is energised.

Together they determine the number of X-rays passing through the object during the
exposure. The greater the number of X-rays, the darker the image. Observe what
happens if mAs is increased too far. The contrast is reduced.

3. kVp determines the energy of the X-rays. Observe what happens to low energy
X-rays for thick objects. You should recognise that no matter how high you
make mA and S, the X-rays will not penetrate.

4.
Radiopaque dye

In the previous activity, you studied how signal is attenuated by tissue

density, and so contrast is dependent on whether or not there is a difference
in density of adjacent tissues.

How can we obtain images that differentiate tissues of equal density?

In the following video, you will learn how we can visualise different
structures by introducing a contrast agent, the path of which is restricted.

Often when we consider X-rays, we think of broken bones or teeth. This is because
they are dense tissues and show up well on X-ray. Soft tissues do not absorb X-rays
and so the signal is far less attenuated. Even more importantly, we cannot
differentiate between the different types of soft tissue. If we could introduce
something dense, this will absorb the X-rays.

Metals are dense, and so opaque to X-rays. And so they can be used to add contrast
to the image. Barium is one such metal. It has an atomic mass of 56, and so is very
dense, compared to tissue. Of course the problem is that barium ions in solution, are
highly toxic and very reactive. However, if we use barium sulphate, this is
extremely insoluble in water, so there are no free ions, and it is a powder. This
powder can be given as a slurry in the water, which can be swallowed. The density
of this mixture can achieve 4.5 g per millilitre.

The radiographer then takes a series of images, using a technique called fluoroscopy.
This is done as the patient drinks or swallows the slurry. Here is an X-ray before
starting.

Can you pick the oesophagus in this image? What about now? You can easily see the
oesophagus, as the slurry passes to the stomach. If there was a partial obstruction in
the oesophagus, or a leak, it could be very easy to see. So in summary the barium
absorbs the X-rays. This means the signal is attenuated. So the image appears dark.
Hopefully, you can now see how we can combine the different concepts to build up
a procedure that can provide the information that the doctor needs.

Fluoroscopy

This video will demonstrate fluoroscopy to image a barium swallow. The

radiographer will prepare a glass of the barium slurry. It is obviously difficult to
swallow lying down, so the whole system, as described in the last session is moved
into the vertical position, and the patient stands in front of the detector. But in this
 system the detector is much longer, and the X-ray tube moves during the imaging
process. The patient is asked to take a mouthful of the slurry, and as they swallow,
the X-ray tube moves from the mouth down to the stomach.

All the time, the detector screen is acquiring images, which are transferred to the
computer. Images can be acquired as a short movie to watch the swallowing
mechanism and the passage of barium as well as much higher resolution still shots.
The patient is then asked to face sideways for a lateral view and the process is
repeated. If you think about this view, you may realize that the bones in the arm will
provide a shadow on the X-ray that could obstruct important pathology. So a third
view with the patient standing at an angle will ensure that the radiologist is able to
see all parts of the esophagus. As this is a digital system, the radiographer can check
the images immediately. Once satisfied that there are no artefacts, the images can be
sent to the physician for review and reporting.

Clinical applications of X-ray

Now that you know how X-rays are produced, and how they are used to
make images, let us look at some clinical examples.

To make it more interesting, each example has an exercise to complete or a

question to answer. They test both your observation and your understanding
of the source of contrast in X-ray imaging.

We hope you have enjoyed this section of BIOIMG101x, and good luck for
Assessment 1.

Table of Contents

Bones

Dental

Chest

Digestive tract

Renal

Other clinical applications using contrast agents