MEDICAL IMAGING The introduction of advanced imaging modalities has significantly improved the diagnostic information available to physicians.

Computer technology has enabled tomographic and three-dimensional reconstruction of images, illustrating both anatomical features (using xrays) and physiological functioning (using -rays emitted from ingested or injected radioactive tracers), free from overlying structures. Since both x-rays and -rays are forms of ionizing radiation, they must be used to minimize damage to the body and its genetic material. Medical imaging modalities Medical imaging systems detect different physical signals arising from a patient and produce images. An imaging modality is an imaging system which uses a particular technique. Some of these modalities use ionizing radiation, radiation with sufficient energy to ionize atoms and molecules within the body, and others use non-ionizing radiation. Ionizing radiation in medical imaging comprises x-rays and -rays, both of which need to be used prudently to avoid causing serious damage to the body and to its genetic material. Non-ionizing radiation, on the other hand, does not have the potential to damage the body directly and the risks associated with its use are considered to be very low. Examples of such radiation are ultrasound, i.e. highfrequency sound, and radiofrequency waves.

Mammography:
X-ray mammography is one of the most challenging areas in medical imaging. It is used to distinguish subtle differences in tissue type and detect very small objects, while minimizing the absorbed dose to the breast. Since the various tissues comprising the breast are radiologically similar, the dynamic range of mammograms is low. Special x-ray tubes capable of operating at low tube voltages (_2530 kV) are used, because the attenuation of x-rays by matter is greater and predominantly by photoelectric absorption at small x-ray energies, resulting in a larger difference in attenuation between similar soft tissues and, therefore, better subject contrast. However, the choice of x-ray energy is a compromise: too low an energy results in insufficient penetration with more of the photons being absorbed in the breast, resulting in a higher dose to the patient. Most modern x-ray units use molybdenum targets, instead of the usual tungsten targets, to obtain an x-ray output with the majority of photons in the 1520 keV range. In order to detect microcalcifications, with diameters that can be less than 0.1 mm, the spatial resolution of the imaging system needs to be optimized. The target within the x-ray tube is angled so as to produce a small focal spot size (0.10.3 mm), and large focal spot-to-film distances (4580 cm) reduce the effects of geometric unsharpness. Compression of the breast, normally to about 4 cm in thickness, reduces x-ray scatter and ensures a more uniform exposure. Immobilization allows a shorter exposure time which minimizes motion blurring. In film mammography, singleemulsion film, without an intensifier screen, is used to minimize the detector contribution to unsharpness.

The contrast of the fluoroscopic image is limited by x-ray scatter in the patient, which can be minimized by using smaller fields of view to limit the volume involved and by using anti-scatter grids. If the fluoroscopic images are digitized, or if a CCD video camera is used, then contrast can be adjusted within the computer system. The acquisition of digital fluoroscopic images can be combined with injection of contrast material and real-time subtraction of pre- and postcontrast images to perform examinations that are generally referred to as digital subtraction angiography, DSA (Fig. 3.21). The result is an image of only the contrast material-filled vessels (Fig. 3.22). Since the images were formed by detection of x-rays that had been attenuated exponentially in the body, subtraction of pre- and post-contrast images must take this exponential attenuation into account by subtracting, pixel by pixel, the logarithm of the respective images: hence the log amplifier in Figure 3.21.

The process of subtracting two images has the unfortunate consequence of producing a noisier subtracted image. Consider subtracting two corresponding pixels: one from the mask (pre-contrast) image, resulting from a signal of 10 000 (100) photons

one from the live (post-contrast) image, resulting from a signal of 9900 (100) photons.

The subtracted image has a pixel value corresponding to 100 141 photons, i.e. the pixels are subtracted, but the noise adds as the square root of the sum of the squares of the amplitudes. The initial two images with signal-to-noise ratios of 100 and 99, respectively, result in a subtracted image with a signal-to-noise ratio of only 0.7! In the normal course of events this would be unacceptable. However, subtracted angiographic images, although noisy, are useful because they make the small differences between the two original images, pre- and post-contrast, very noticeable or conspicuous and the small contrast-laden vessels are easily seen. They are said to have high conspicuity, rather like the spot-the-difference pictures in popular magazines.

This pixel shifting tends to be a trial-and-error process, involving a combination of shifts in different directions and by differing amounts. Motion artifacts can be a significant problem in cardiac studies, resulting from the involuntary motion of the soft tissues.

CT imaging:
CT imaging is the primary digital technique for imaging the chest, lungs, abdomen and bones due to its ability to combine fast data acquisition and high resolution, and is ideally suited to three-dimensional reconstruction. It is particularly useful in the detection of pulmonary (i.e. lung) disease, because the lungs are difficult to image using ultrasound and MRI. It is often used to diagnose diffuse diseases of the lung such as emphysema, which involves a sticky build-up of mucus in the lungs, and cystic fibrosis, which leads to irreversible dilation of the airways.

Activity 3.3 uses a stack of images of a brain showing hydrocephalus, in which excessive accumulation of cerebrospinal fluid CSF results in an abnormal dilation of the ventricles (spaces)

in the brain, causing potentially harmful pressure on the brain tissues. The user can move through the stack to identify the slices which show enlarged ventricles.

SPECT imaging:
In single-photon emission computed tomography, SPECT, a rotating gamma camera, with one, two or three detector heads, rotates around and as closely as possible to the patient because spatial resolution decreases with the distance from the collimator. Sensitivity increases and acquisition time decreases with more detector heads. The different acquired projections are used to reconstruct cross-sectional or three dimensional images by filtered back projection. Reconstruction computations are more complicated than with x-ray computed tomography because the detected signals depend upon both the spatial distribution of the radioisotopes and the attenuation properties of the voxels. As with x-ray computed tomography imaging, the main advantage of SPECT

over planar imaging is the absence of superpositioning of overlying and underlying signals. A time-sequence of sequential SPECT images of the heart can easily be viewed as an animated sequence . SPECT studies of the brain are used to diagnose a large range of diseases that cause altered blood perfusion (Fig. 3.38(i)). SPECT scans can be used to measure cardiac wall thickness (Fig. 3.38(ii)). Pseudocolor is often added to the images to increase clarity.

PET imaging:

Positron emission tomography, PET, is the most recent nuclear medicine imaging technique: in common with the others, it measures physiological function (e.g. perfusion, metabolism), rather than gross anatomy. A small, positron-emitting radioisotope with a short half-life (such as carbon-11, 11C (about 20 min), nitrogen-13, 13N (about 10 min), oxygen-15, 15O (about 2 min), and fluorine-18, 18F (about 110 min)) is incorporated into a metabolically active molecule (such as glucose, water or ammonia), and injected into the patient. Such labeled compounds are known as radiotracers. When a positron, i.e. a positively charged electron, is emitted within a patient, it travels up to several millimeters while losing its kinetic energy. When the slowly moving positron encounters an electron, they spontaneously disappear and their rest masses are converted into two 511 keV annihilation (gamma ray) photons, which propagate away from the annihilation site in opposite directions.

The patient is surrounded by multiple rings of gamma photon detectors, so that no detector rotation is required. Positron emission tomography, PET, is distinct from single-photon emission computed tomography, SPECT, in that two -ray photons are produced at the same time. The output of detectors on opposite sides of the PET scanner is analyzed by a coincidence detector, which only counts events that are simultaneous to within a user-set time window (_2 20 ns); this ensures that only the 511 keV photons are counted. Simultaneous triggering reveals the line of sight of the two photons, and the original positron-emitting radiopharmaceutical must be somewhere along that line. The intersection of many such lines delineates the distribution of the pharmaceutical. PET images (Fig. 3.39) have higher signal-to-noise ratio and better spatial resolution (_2mm) than planar scintigraphy and SPECT images. However, PET systems are much more expensive. Cyclotrons are required to produce the short-lived positron-emitting isotopes, due to their short half-lives. Few hospitals and universities are capable of maintaining such systems, and most clinical PET is supported by third-party suppliers of radiotracers which can supply many sites simultaneously. This limitation restricts clinical PET primarily to the use of radiotracers labeled with fluorine-18 (T 110 minutes), which can be transported a reasonable distance before use, or to rubidium-82 (T 75 seconds), which can be created in a

portable generator and is used for myocardial perfusion studies. To facilitate the process of correlating structural and functional information, scanners that combine x-ray CT and radionuclide imaging, either SPECT or PET, have been developed. These dual-modality systems use separate detectors for x-ray and radionuclide imaging, with the detectors integrated on a common gantry. Because the two scans can be performed in immediate sequence during the same session, with the patient not changing position between the two types of scans, the two sets of images are more precisely registered. In the fused image the radionuclide distribution can be displayed in color on a gray-scale CT image to co-register the anatomical and physiological features and thereby improve evaluation of disease.

Doppler imaging:
Blood velocity measurements are essential in calculating cardiac output and diagnosing stenosis, narrowing, of the arteries. The Doppler effect can be used to determine blood velocity and interlace this information with B-mode scanning, as a so-called duplex scan. The Doppler effect is familiar in the form of the increased frequency of a moving sound source, such as a train whistle or police siren, as it approaches, and the reduced frequency, as it passes by. The relative change in frequency, f/f, depends on the velocity of the sound emitter, V, relative to the speed of sound in air, Vs. Thus:

where the refers to the sound source traveling towards (+) or away from () the receiver.

Doppler measurements are usually displayed as a time series of spectral Doppler plots (Fig. 4.8); there is no spatial (i.e. depth) information.

Ultrasound:
There are a wide range of applications of ultrasound imaging as a result of its noninvasive, non-ionizing nature, and its ability to form real-time axial and three-dimensional images. The tissues of interest need to reflect sufficient ultrasound energy; this limits the method to soft tissues, fluids and small calcifications preferably close to the surface of the body and unobstructed by bony structures. Ultrasound is most commonly employed in examinations of the abdomen and pelvis. In obstetrics, fetal head size and fetal length are used as measures of fetal maturity and health, while spinal morphology can be used to detect the presence of abnormalities such as spinal bifida. Doppler imaging can be used to measure fetal blood velocity and cardiac function.

Ultrasound imaging can be used to complement x-ray mammography in the diagnosis of breast cancer (Fig. 4.9). It can help determine whether a lump is a fluid-filled cyst or a solid mass, and is particularly useful in women with dense breast tissue and with young women, because their tissue is relatively opaque to x-rays.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) is a non-ionizing technique that uses radiofrequency (200MHz2 GHz) electromagnetic radiation and large magnetic fields (around 12 tesla (T), compared with the Earths magnetic field of about 0.5 104 T). The large magnetic fields are produced by superconducting magnets, in which current is passed through coils of superconducting wire whose electrical resistance is virtually zero. MRI images provide anatomical and physiological details, i.e. structure and function, with full three-dimensional capabilities, excellent soft tissue visualization, and high spatial resolution (~1mm). Like x-ray CT, it is a tomographic imaging modality. Image reconstruction, while conceptually equivalent to that in CT, is obtained from the raw signals collected in frequency space. With sufficient slice images, the image data is practically three-dimensional and it is possible to reconstruct the data in different two-dimensional planes . Scans last several minutes, rather than a few seconds as in x-ray CT, so that patient motion can be a problem. Furthermore, MRI scanners are several times as costly as a CT scanner because of the expensive superconducting magnet required.

Nuclear magnetic resonance

MRI imaging is based on nuclear magnetic resonance (NMR). Nuclei are composed of nucleons, either neutrons or protons. Nuclei with unpaired nucleons behave like small magnets, with an associated magnetic moment. The hydrogen nucleus, a single proton, is of particular importance in MRI imaging because of its abundance in biological tissue, and all current MRI scanners use the proton signal.