X-ray image intensifier

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An x-ray image intensifier (XRII) is an image intensifier that converts x-rays into visible light at higher intensity than mere fluorescent screens do. Such intensifiers are used in x-ray imaging systems (such as fluoroscopes ) to allow low-intensity x-rays to be converted to a conveniently bright visible light output. The device contains a low absorbency/scatter input window, typically aluminum, input fluorescent screen, photocathode, electron optics, output fluorescent screen and output window. These parts are all mounted in a high vacuum environment within glass or more recently, metal/ceramic. By its intensifying effect, It allows the viewer to more easily see the structure of the object being imaged than fluorescent screens alone, whose images are dim. The X-ray II requires lower absorbed doses due to more efficient conversion of x-ray quanta to visible light. This device was originally introduced in 1948.[1]

Operation[edit]

Schematic of an x-ray image intensifier

The overall function of an image intensifier is to convert incident x-ray photons to light photons of sufficient intensity to provide a viewable image. This occurs in several stages. The first is conversion of x-ray photons to light photons by the input phosphor. CsI:Na is typically used due to its high conversion efficiency thanks to high atomic number and mass attenuation coefficient.[2] The light photons are then converted to electrons by a photocathode. A potential difference (25-35 kilovolts) created between the anode and photocathode then accelerates these photoelectrons while electron lenses focus the beam down to the size of the output window. The output window is typically made of silver-activated zinc-cadmium sulfide and converts incident electrons back to visible light photons.[2] At the input and output phosphors the number of photons is multiplied by several thousands, so that overall there is a large brightness gain. This gain makes image intensifiers highly sensitive to x-rays such that relatively low doses can be used for fluoroscopic procedures.[3][4][5][6]

History[edit]

X-ray image intensifiers became available in the early 1950s and were viewed through a microscope.[7]

Viewing of the output was via mirrors and optical systems until the adaption of television systems in the 1960s.[8] Additionally, the output was able to be captured on systems with a 100mm cut film camera using pulsed outputs from an x-ray tube similar to a normal radiographic exposure; the difference being the II rather than a film screen cassette provided the image for the film to record.

The input screens range from 15–57 cm, with the 23 cm, 33 cm and 40 cm being among the most common. Within each image intensifier, the actual field size can be changed using the voltages applied to the internal electron optics to achieve magnification and reduced viewing size. For example, the 23 cm commonly used in cardiac applications can be set to a format of 23, 17, and 13 cm. Because the output screen remains fixed in size, the output appears to "magnify" the input image. High-speed digitalisation with analogue video signal came about in the mid-1970s, with pulsed fluoroscopy developed in the mid-1980s harnessing low dose rapid switching x-ray tubes. In the late 1990s image intensifiers began being replaced with flat panel detectors (FPDs) on fluoroscopy machines giving competition to the image intensifiers.[9]

Clinical applications[edit]

Main article: Fluoroscopy

"C-arm" mobile fluoroscopy machines are often colloquially referred to as image intensifiers (or IIs),[10] however strictly speaking the image intensifier is only one part of the machine (namely the detector).

Fluoroscopy, using an x-ray machine with an image intensifier, has applications in many areas of medicine. Fluoroscopy allows live images to be viewed so that image-guided surgery is feasible. Common uses include orthopedics, gastroenterology and cardiology.[11] Less common applications can include dentistry.[12]

Image intensifier configurations[edit]

A system containing an image intensifier may be used either as a fixed piece of equipment in a dedicated screening room or as mobile equipment for use in an operating theatre.

Permanent/Fixed Fluoroscopic Systems[edit]

There are two main configurations of permanently installed fluoroscopic systems. One class commonly utilizes a radiolucent patient examination table with an under-table mounted tube and an imaging system mounted over the table, while the other is commonly referred to as a C-arm system used where greater flexibility in the examination process is needed such as neuro or cardiac imaging.

Modern imaging systems on both configurations are limited in capability only by the desired features the users will want. All frame rates, storage (local or PACS), image capture devices etc. are now far lower in cost than before, software configurable and based on COTS components for all but the camera/II or flat panel devices.

The non-C-arm based systems are used in most X-ray departments as 'screening rooms'. The types of investigations for which this machine can be used for is vast, including:

  • Barium studies (swallows, meals, enemas)
  • Endoscopy studies (ERCP) (Some sites will opt for a portable C-arm system for this)
  • Fertility studies (HSG)

The C-arm systems are commonly used for studies requiring the maximum positional flexibility such as:

  • Angiography studies (peripheral, central and cerebral)
  • Therapeutic studies (Line placements e.g. Permacath/Hickman, transjugular biopsies, TIPS stent, embolisations)
  • Cardiac studies (PTCA)
  • Orthopedic procedures (e.g. ORIF, DHS, MUA, spinal surgery) - again generally using a portable C-arm maximum flexibility in positional use. There are very few permanently installed C-arms in an Operating Room (OR) setting. The workflow seldom justifies this sort of dedication of one OR or Permanent C-arm

Mobile Fluoroscopic System[edit]

C-arm of a mobile X-ray unit containing an image intensifier (top)

General configuration and range of movements[edit]

A mobile fluoroscopy unit (or "c-arm") generally consists of two units, the X-ray generator and image detector (II) on a portable imaging system (C-arm) and a separate workstation unit used to store and manipulate the images. The imaging system unit can perform a variety of movements that allow for use in a range of surgical procedures such as cardiology, orthopedics and urology. This unit provides the appropriate structure to mount an image intensifier and an X-ray tube with a beam limiting device positioned directly opposite from and aligned centrally to each other.

The C-arm is capable of many movements:

  • Horizontal travel: about 200 mm
  • Orbital travel: about 115 degrees
  • Motorized vertical travel: 460 mm
  • Wig-wag about +/-12 cm (entire C-arm and Image Intensifier)
  • C-arm rotation about the horizontal axis +/- 210 degrees

The X-ray generator, dose control system and collimator controls are usually housed in the chassis on which the C-arm is mounted. All of the control systems are closed loop systems which are directed by the master controller initial program settings. The master controller generally is found in the work station. User controls on the C-arm allow the operator to modify the operation of the system while in use. I.e. format size, slot collimator position, dose rate etc.

The imaging system must be compact and lightweight to allow easy positioning with adequate space to work around and a wide range of motion while remaining inflexible enough so as to avoid misalignment due to flexion caused by the mass of the X-ray tube or Image system assemblies.

Image intensifier size and features[edit]

X-ray systems may be fitted with a range of different types of image intensifiers; typically 16 cm or 22 cm.

Typical specifications for a 16 cm intensifier are:

  • Maximum resolution is 44 lp/cm at the centre of the screen.
  • Anti-scatter grid of 8:1, focused at 90 cm.
  • Removable cassette holder that is mounted on the image intensifier and holds a 24X30 film.
  • Rotation 360 degrees

Typical specifications for a 22 cm intensifier are:

  • Resolution is 44 lp/cm at the centre of the screen.
  • Magnification mode - allows a maximum resolution of 51 lp/cm at the centre of the screen
  • Stationary anti-scatter grid 10:1, focused at 90 cm.
  • Removable cassette holder that is mounted on the image intensifier and holds a 24X30 film.
  • Rotation 360 degrees

Flat panel detectors[edit]

Main article: Flat panel detector

Flat Detectors are an alternative to Image Intensifiers. The advantages of this technology include: lower patient dose and increased image quality because the X-rays are always pulsed, and no deterioration of the image quality over time. Despite FPD being at a higher cost than II/TV systems, the noteworthy changes in the physical size and accessibility for the patients is worth it, especially when dealing with paediatric patients.[9]

Feature Comparison table of II/TV and FPD Systems[edit]

Feature Digital Flat Panel Conventional II/TV
Dynamic range Wide, about 5,000:1 Limited by TV, about500:1
Geometric distortion None Pin-cushion and ‘S-distortion
Detector size (bulk) Thin profile Bulky, significant with large FOV
Image area FOV 41 x 41cm 40cm diameter (25% less area)
Image quality Better at high dose Better at low dose

Feature comparison of II/TV and FPD Systems[9]

3D imaging[edit]

Some imaging systems using either image intensifiers or flat panel detectors are capable of taking images in multiple planes that can be used to reconstruct a 3D volume of the patient anatomy. This capability is typically used for surgical navigation. It can also be helpful for surgeons who want to check the placement of implanted devices in the patient, such as spinal screws. See:

See also[edit]

X-ray detector

References[edit]

  1. ^ Krestel, Erich (1990). Imaging Systems for Medical Diagnostics. Berlin and Munich: Siemens Aktiengesellschaft. pp. 318–327. ISBN 3-8009-1564-2. 
  2. ^ a b Wang, Jihong; Blackburn, Timothy J. (September 2000). "The AAPM/RSNA Physics Tutorial for Residents". RadioGraphics. 20 (5): 1471–1477. doi:10.1148/radiographics.20.5.g00se181471. 
  3. ^ Hendee, William R.; Ritenour, E. Russell (2002). Medical Imaging Physics (4th ed.). Hoboken, NJ: John Wiley & Sons. p. 237. ISBN 9780471461135. 
  4. ^ Schagen, P. (31 August 1979). "X-Ray Image Intensifiers: Design and Future Possibilities". Philosophical Transactions of the Royal Society A: Mathematical, Physical and Engineering Sciences. 292 (1390): 265–272. doi:10.1098/rsta.1979.0060. 
  5. ^ Bronzino, edited by Joseph D. (2006). Medical Devices and Systems. (3rd ed.). Hoboken: CRC Press. p. 10-5. ISBN 9781420003864. 
  6. ^ Singh, Hariqbal; Sasane, Amol; Lodha, Roshan (2016). Textbook of Radiology Physics. New Delhi: JP Medical. p. 31. ISBN 9789385891304. 
  7. ^ Airth, G. R. (31 August 1979). "X-Ray Image Intensifiers: Applications and Current Limitations". Philosophical Transactions of the Royal Society A: Mathematical, Physical and Engineering Sciences. 292 (1390): 257–263. doi:10.1098/rsta.1979.0059. 
  8. ^ "Radiography in the 1960s". British Institute of Radiology. Retrieved 5 January 2017. 
  9. ^ a b c Seibert, J. Anthony (22 July 2006). "Flat-panel detectors: how much better are they?". Pediatric Radiology. 36 (S2): 173–181. doi:10.1007/s00247-006-0208-0. PMC 2663651Freely accessible. 
  10. ^ Krettek, Christian; Aschemann, Dirk, eds. (2006). "Use of X-rays in the operating suite". Positioning Techniques in Surgical Applications. Berlin: Springer. p. 21. doi:10.1007/3-540-30952-7_4. ISBN 978-3-540-25716-5. 
  11. ^ "Fluoroscopy: Background, Indications, Contraindications". Medscape. 7 April 2016. Retrieved 5 January 2017. 
  12. ^ Uzbelger Feldman, D; Yang, J; Susin, C (2010). "A systematic review of the uses of fluoroscopy in dentistry.". The Chinese journal of dental research : the official journal of the Scientific Section of the Chinese Stomatological Association (CSA). 13 (1): 23–9. PMID 20936188.