Resident Physics Lectures

Introduction To Medical Imaging

Physics
Prof. J.K Tonui, PhD

School of Medicine,
Department of Radiology & Imaging
 Learning Objectives
 By the end of this lecture, the student is expected to:

 Discuss the basic principles and applications of the

mainstream imaging techniques in radiological

departments.
 Appreciate why physics is an integral component in

Radiology and Imaging training.

2 RIB 810, 811, 812 Medical Physics 1/15/2018

 Introduction
 Medical physics

 Deals with the application of physics principles in medicine, and

 In particular, the use of ionizing radiation for diagnosis and therapy of

diseases in human beings.

 Main stream imaging techniques are:

 Radiography – use x-rays radiation,

 Nuclear medicine – use -rays radiation,

 MRI – use magnetic field, and

 Ultrasound scanning – use high frequency sound waves.

3 RIB 810, 811, 812 Medical Physics 1/15/2018

 Situation Before 20th Century
 Prior to 20th century, the only tools used then for investigations in

clinical medicine were:

1. Microscope – to view and analyze body samples (blood,
sputum, etc.) drawn from pts in clinical laboratories.
2. Thermometer – to measure body temperature (normal body
= 37.0 oC or 98.6 oF).
3. Knife – for exploratory surgery (to open up pts).
4. Stethoscope – to detect and measure heartbeats in pts.
4 RIB 810, 811, 812 Medical Physics 1/15/2018
 Genesis of Medical Imaging
 Before 1896,

 No means existed to examine internal body parts, and

 Physicians diagnosed and treated patients without being able to see

their ‘insides’ except thro’ exploratory surgeries in theaters.

 Medical imaging

 Started with the discovery of X–rays by Roentgen in 1895 and

 Since then, has continued to enlarge and improve to date, and

 The specialty was called Roentgenology, and the radiologists were

referred as Roentgenoligists.

5 RIB 810, 811, 812 Medical Physics 1/15/2018

 Medical Imaging - Radiology
 Medical imaging

 Is technically called radiology, and

 Is a medical specialty that is highly dependent on technology (i.e.

rely on equipments to obtain information) and

 Since its inception over 100 years ago, radiology has improved

in many aspects, e.g. development of new modalities, complexity of

image acquisition, increasily being used all over the world for diagnosis
of almost all diseases,
6 RIB 810, 811, 812 Medical Physics 1/15/2018
 Radiology
 Origin of the name ‘radiology’ is historical:

 X- and  rays were mysterious/strange rays when they were

discovered in 1895 and 1896 respectively, but

 Were reminiscent to another developing and not well

understood phenomenon at the time - radio communication, and

 It was natural then to assimilate the two phenomena, and

 Hence, sources which emitted these rays were termed radio-

active, and its clinical application as radiology.

7 RIB 810, 811, 812 Medical Physics 1/15/2018
 Medical Imaging or Radiology
 Computer integration and the continuous innovation in imaging
techniques
 Have increased the role played by the Radiologists in the diagnosis and
treatment of human diseases in this 21st century, which
 Has increased the demand for radiological services in the modern medicine
for provision of quality health care to patients (evidence based) all over
the world today, for instance
 In Kenya, every county is now equipping their major hospitals and health
facilities with radiological equipments to provide this service to their
people or “voters.”
8 RIB 810, 811, 812 Medical Physics 1/15/2018
 Medical Imaging Overview
 All medical imaging techniques

 Require some physical energy in order to produce images of the

internal body tissues or organs and must be able to:

o Penetrate thro’ the human body, and

o Interact with internal body tissues or organs.

 In other words, the energy entering the body must be modified or

manipulated by the internal body tissues (i.e. must do work).

9 RIB 810, 811, 812 Medical Physics 1/15/2018

 Visible Light
 Visible light

 Is an EM energy that is detected by the human eye, but

 Has shallow penetration in human body, hence

 Is not useful for radiological imaging, except

o For direct visual observation or examination of pts;

o For physical interpretation of X-ray films in the view-boxes, and

o In endoscopy, using laser light to view and image non-invasively GI

tracks of the pts.

10 RIB 810, 811, 812 Medical Physics 1/15/2018

 Energies used in Imaging
 In medical imaging,

 Several forms of energies are used to produce images of internal

body parts, and

 These energies are broadly classified as:

o Electromagnetic (EM) energy or radiation (e.g. light, x-

rays, -rays and magnetic field) and

o Mechanical energy – usually high frequency sound waves called

ultrasound .

11 RIB 810, 811, 812 Medical Physics 1/15/2018

 Diagnostic Radiology
 Medical imaging uses:

 EM radiation outside the visible light region:

o x-rays (radiography, CT, Fluoroscopy, mammography),

o magnetic field (MRI), and

o Gamma () rays (Nuclear Medicine , NM).

 Mechanical energy or high frequency sound

o Ultrasound scan.

12 RIB 810, 811, 812 Medical Physics 1/15/2018

 Interaction of Energy and Tissue
 For the image to be produced,

 The radiation must penetrate and interact (see Fig. in next

slide) with the body tissues/organs, but

 If they penetrate thro’ the body and fail to interact with the

tissues/organs, then

 The energy transmitted thro’ and detected outside the body

would not contain any useful information for image production.

13 RIB 810, 811, 812 Medical Physics 1/15/2018

 Interaction of Energy and Tissue

Transmitted
Energy
Beam
Received on
Image
Receptor for
Image
Formation

Incident
Beam Attenuation (interaction)
of Energy Beam inside Pt.’s
Body
14 RIB 810, 811, 812 Medical Physics 1/15/2018
 Interaction of Energy and Tissue
 Five interaction processes between radiation and body tissues

are:
 Coherent/Raleigh scattering,

 Photoelectric effect (PE),

 Compton scattering (CS),

 Pair production, and

 Photodisintegration.

15 RIB 810, 811, 812 Medical Physics 1/15/2018

 Interaction of Energy and Tissue
 Absorbed
 completely removed from beam,
 ceases to exist (annihilated). X
 Scattered
 Change in direction,
 Carry no useful information,
All these processes
 Is a source of noise. are desirable for
image production
 Nothing
 Photon passes unmolested i.e.
penetrate undeflected or removed

16 RIB 810, 811, 812 Medical Physics 1/15/2018

 Image Quality and Pt. Safety
 Radiation used in radiology are hazardous to human beings

 Hence, we should strive for an optimal compromise between

their clinical utility and the radiation dose to patients, and

 High quality images require high amount of radiation but then

result to high patient dose, and

 Normally, in medical imaging, we should not go for high quality

images at the expense of patient safety, but

 Should balance the two with bias towards the patient safety.

17 RIB 810, 811, 812 Medical Physics 1/15/2018

 Image Quality and Pt. Safety
 In the practice of radiology,

 The safety of the patient is the first priority or given

preferences over image quality, or

 In other words, the pt. comfort is considered first when

acquiring medical images, hence

 Excessive pt. dose in the pursuit of a perfect image is not

acceptable.

18 RIB 810, 811, 812 Medical Physics 1/15/2018

 Image Quality and Pt. Safety
 Quality of a medical image

 Does not necessarily depend on aesthetic appearance, i.e.

 Aesthetic appearance is optional, although inherent in US,

NM & MRI modalities for enhancing image interpretation,

 In other words, artistic appraisal of medical images counts

very little but a great deal of technical evaluation is

emphasized.

19 RIB 810, 811, 812 Medical Physics 1/15/2018

 Types of Modalities
 Common medical imaging modalities are:

 Radiography or X-ray imaging

o General/convectional x-ray imaging,

o Fluoroscopy,

o Mammography, and

o Computed Tomography (CT).

 Magnetic Resonance Imaging (MRI);

 Nuclear Medicine (NM), and

 Ultrasound (US) Imaging.

20 RIB 810, 811, 812 Medical Physics 1/15/2018

 Radiography
 Radiography:

 First modality to be used for medical imaging,

and
 Started with discovery of of X-rays by

Roentgen on 22/11/1895, and

 He imaged the hand of his wife on 8/12/1895

(just 2 weeks), which

 Is considered as the 1st radiographic image in

the world as shown in Fig. beside.

21 RIB 810, 811, 812 Medical Physics 1/15/2018
 Radiography
 Roentgen

 Assigned the letter "x" to represent the unknown nature of the

new ray in accordance to mathematical conventions and hence

the term x-rays was born, but
 Was able to understand its properties within a short time, and

 Its application for medical imaging spread quickly throughout

the world as the first ever imaging procedure for seeing internal
hidden parts of the human body.

22 RIB 810, 811, 812 Medical Physics 1/15/2018

 Radiography
 Radiography

 Is a transmission projection imaging modality,

where
 Radiation are produce by x-ray tube on one

side of the body and

 Then passed thro’ the patient and transmitted

rays are captured by a detector (e.g. x-ray

film) as shown in the Fig. beside.
23 RIB 810, 811, 812 Medical Physics 1/15/2018
 Types of Radiography
 Several modalities use X-rays for imaging:

 Convectional radiography or simply radiography;

 Fluoroscopy;

 Mammography, and

 Computed Tomography (CT).

 Note that

 All the modalities were analogue initially except CT scan which

was inherently digital but all of them are now digitized.

24 RIB 810, 811, 812 Medical Physics 1/15/2018
 Operation of Radiography
 In x-ray imaging,

 Pt. is positioned between X-ray tube and film (IR);

 Tube is turn ON for a very short time (½ s), where

 Streams of x-rays are produced, and passed through the patient

body, where
 A large fraction is absorbed inside the pt. body, and

 The remaining fraction is transmitted thro’ the body and is

captured by the film exposing it and producing the image.

25 RIB 810, 811, 812 Medical Physics 1/15/2018
 Convectional Radiography
 Convectional radiography

 Uses energetic x-rays depending on

thickness of the part being imaged,

and Normal

 Is widely used for various

investigations such as chest x-ray (PA

or AP), musculoskeletal, abdomen,
bone fracture, etc.
Abnormal
26 RIB 810, 811, 812 Medical Physics 1/15/2018
 Convectional X-Ray Imaging
Pros Cons
o Widely available o Ionizing Radiation
o Inexpensive o Relatively insensitive
o Doesn’t require advanced o Requires patient
technologist knowledge cooperation
o Can be performed quickly
o Portable

27 RIB 810, 811, 812 Medical Physics 1/15/2018

 Fluoroscopy
 Fluoroscopy

 Uses continuous x-ray streams to produce

movie-like images of internal tissues, and

 Used for imaging soft tissues such as GI

truck and blood flow by using contrast

agents (e.g. barium meal), and
 For placement of catheters .

28 RIB 810, 811, 812 Medical Physics 1/15/2018

 Fluoroscopy
Pros Cons
o Requires ingestion/
o Widely Available
injection of contrast
o Inexpensive
o Patient cooperation
o Functional and Anatomic
o Time consuming
o No sedation required

29 RIB 810, 811, 812 Medical Physics 1/15/2018

 Mammography
 Mammography

 Is radiographic technique dedicated for breast imaging, and

 Is very sensitive in early detection of breast anomalies such as

masses and calcification, and

 Is used for both screening and diagnosis, where

o Screening is used for investigating presence of anomalies, and

o Diagnosis is done to determine whether detected anomalies are

malignant or benign and uses more projections.

30 RIB 810, 811, 812 Medical Physics 1/15/2018

 Mammography
 Mammography

 Uses a special type of X-ray tube – mammo x-ray tube, which

 Differs in many aspects from the convectional X-ray tube, and

 In particular, the low values of technique factors used, usual values

of kV is less than 30 kVp , which

 Produces low energy X-rays that interact very well with the soft

tissues of the breast.

31 RIB 810, 811, 812 Medical Physics 1/15/2018

 Mammography X-ray Unit

Special C-arm
mammography X- Mammography Imaging Procedure
ray Tube.

32 RIB 810, 811, 812 Medical Physics 1/15/2018

 Computed Tomography (CT)
 CT

 Is a radiographic technique that uses several projections to

produce images of slices of the section being imaged, and

 Became clinically available for the first time in the early 1972

and
 Is the first digital radiography, i.e. the 1st x-ray modality to use

a computer.

33 RIB 810, 811, 812 Medical Physics 1/15/2018

 Computed Tomography (CT)
 CT images

 Are produced by passing x-rays thro’

the body at different angles by rotating

the x-ray tube around the body, and
 Synchronized detectors on the other

side of the pt. and opposite the x-ray

tube collect the transmitted x-rays as
projection data and fed to the computer
for image reconstruction.
34 RIB 810, 811, 812 Medical Physics 1/15/2018
 Computed Tomography (CT)
 CT

 Produces high quality images of individual slices of body tissues.

 The advantage of a tomographic X-ray images over

convectional X-ray images is

 Its ability to display the anatomy in a slab (slice) of tissue in the

absence of over- or underlying structures (i.e. no interference),

as illustrated in the next slide.

35 RIB 810, 811, 812 Medical Physics 1/15/2018

 Basic Principle-CT Scanning

PA chest image

yields information
concerning
• height and width,
integrated along the
depth of the patient,
Lateral projection
provides information
about the height and
depth of the patient,
integrated over the •The numerous data points collected in this
width dimension manner are synthesized by a computer into a
tomographic image of the patient.
•The term tomography refers to a picture (-
graph) of a slice (tomo-).
36 RIB 810, 811, 812 Medical Physics 1/15/2018
 Nuclear Medicine Imaging
 Nuclear medicine (NM)

 Uses radioactive substance, also called radioisotope or

radionuclide, or radiotracer, but

 In clinical medicine is called radiopharmaceutical, where

 Minute amount is administered to the patient thro’ either

injection or ingestion or inhaling, depending on their physical

state (liquid, solid and gas).

37 RIB 810, 811, 812 Medical Physics 1/15/2018

 Nuclear Medicine Imaging
 The administered radioisotope

 Undergoes both metabolic and physiologic decay once in the body

and emits -rays, which

 Then interact with the internal body tissues, and

 Those existing the body are captured by gamma cameras

positioned outside the pt. and information they carry are

passed to system’s computer for image construction.

38 RIB 810, 811, 812 Medical Physics 1/15/2018

 Nuclear Medicine Imaging
 Unlike X-ray imaging,

 Which is a transmission imaging

technique,
 NM is an emission imaging technique,

which
 Means radiation are produced inside

patient’s body and come out of it

(emitted) and captured by detectors
positioned around the patient.
39 RIB 810, 811, 812 Medical Physics 1/15/2018
 NM Imaging System
 Fig.
 Shows components of NM
system, and
 Two types –SPECT & PET.

40 RIB 810, 811, 812 Medical Physics 1/15/2018

 Magnetic Resonance Imaging (MRI)
 Real name

 Is Nuclear Magnetic Resonance Imaging (NMRI), and

 Since the word “Nuclear” was associated to disasters (Chernobyl,

Hiroshima, nuclear weapons), it was scaring to patients, and

 Was necessary to baptize it and give a more friendly name,

which lead to removal of ‘nuclear’ and shortening to Magnetic

Resonance Imaging (MRI) - less scaring.

41 RIB 810, 811, 812 Medical Physics 1/15/2018

 MRI
 MRI

 Produces high quality images of the soft-tissues, based on either

structure or function of the tissue, and

 Provides much greater contrast between soft tissues that differ

marginally in physical properties than CT does, and

 Is usually more useful for imaging the neurological (brain),

musculoskeletal, cardiovascular, and cancerous tumors.

42 RIB 810, 811, 812 Medical Physics 1/15/2018

 MRI
 MRI

 Uses magnetic field, hence safer than radiography which uses

ionizing radiation, but

 Typical magnetic field used by MRI equipment is extremely

strong, about 10,000 to 60,000 times stronger than the earth's

magnetic field (typically 1.5 T), and
 Hence, patients and staff need to be protected from the missile

effects due to the attraction of ferromagnetic materials.

43 RIB 810, 811, 812 Medical Physics 1/15/2018
 MRI
 MRI

 Utilizes the magnetic properties of the nucleus of an atom to

produce images of the tissues, and

 Normally uses hydrogen nucleus (normally called a proton, since it

has one proton in its nucleus), and

 Is used because it is very abundant in the human body (each tissue

contains 1018 protons/mm3), and has other useful magnetic

properties.
44 RIB 810, 811, 812 Medical Physics 1/15/2018
 MRI
 During MRI proecdure,

 Patient is placed inside a strong magnetic field to magnetize him

or her, and
 A RF pulse from a coils positioned near the pt. is switched on

briefly to excite the precessing proton, and

 When switched off protons will go back to their equilibrium

position by emitting back the RF signals which are detected by

the same coil and fed to the computer for image production.
45 RIB 810, 811, 812 Medical Physics 1/15/2018
 Ultrasound
 Ultrasound (US) imaging

 Uses sound to ‘see’ the internal parts of the human body, and

 US is high frequency sound with frequency above 20 kHz, i.e.

upper limit of audible sound to human ear, but

 Medical US uses frequencies between 2 MHz to 16 MHz, and

 Depth of penetration is inversely proportional to US

frequency, but resolution is directly proportional to US

frequency.
46 RIB 810, 811, 812 Medical Physics 1/15/2018
 Ultrasound
 US scan

 Is widely used for imaging of soft internal tissues, for instance

o Tendons, muscles, vessels and organs for possible pathology or

lesions;
o Obstetric during pregnancy (uses non-ionizing radiation hence

safer to developing foetus), and

o Blood flow is monitored or measured using Doppler US.

47 RIB 810, 811, 812 Medical Physics 1/15/2018

 Ultrasound
 Other uses of US include:

 Biopsies or drainage of fluid collection in the body, and

 Ultrasound thermotherapy for deep tissues massaging.

 In US scan

 The sonographer holds a scan-head with his/her hand and

strokes it directly on skin around the region to be imaged and

 Echoes of US pulses send are received and send to the computer

for image reconstruction.

48 RIB 810, 811, 812 Medical Physics 1/15/2018
 How US Works
 A thin layer of jelly is placed between the
probe and the skin to make sure all the
sound enters the body.
Ultrasound
 The probe contains a transmitter and probe
a receiver.
 A pulse of ultrasound is sent out by the
transmitter.

 The pulse is reflected from a surface and

skin
returns to the receiver.

 The ultrasound machine measures how

long it takes for the pulse to return

Body tissue
RIB 810, 811, 812 Medical
49 Physics
(muscle etc)
1/15/2018
 How US Works
 US scan

 Uses pulse-echo technique, where

 Transducer sends US pulse into pt. body, which

 Is reflected whenever it encounters an interface, and

 Echo is detected by the transducer, and

 Round trip time is measured and used to determine

t rt
depth of interface from skin: d
2
 Appearance is measured in terms of amplitude of the

echo.

50 RIB 810, 811, 812 Medical Physics 1/15/2018