3.

Radiation physics, biology and safety

Fitridge Chapter 30 and 31

X-Rays
 A forms of electromagnetic radiation, lying on a spectrum with light and radio waves
 X-rays have a short wavelength and therefore carry a high amount of energy
 X-rays are produced by a cathode-ray tube when high speed electrons strike a solid
target and rapidly decelerate releasing energy.
 Energy is carried through space in a bundle of energy called a photon.
 Photons travel at the speed of light and carry no mass or charge.
 X-ray is different to other forms of non-ionising radiations it is can displace outer
electron from an atoms when they collide (light and microwaves can’t do this).

 When x-rays interact with the body they are absorbed

 Accounts for the difference in transparency.
 If accumulation is too large, can cause DNA damage.

Scatter Radiation
 X-Rays that enter a patient from the primary beam can either be fully absorbed or pass
straight through
 X-rays that exit the patient are scatter- highest point occurring at the entry point of the
patients skin.
 It is the largest source of radiation to the operator and staff.
 Increase in distance, there is a exponential decrease in number of photons per unit area
 Doubling the distance from the X-ray Source decreases the exposure by 4.
 X=1/d2

Measuring Radiation Dose

 There are two different nomenclature systems
 No direct way to measure radiation abspriton in the bdoy

Conceptual Measurement

Absorbed Dose: Unit= Gray (Gy)

 This is a concentration of energy deposition by radiation into the absorbing tissue.
 It gives an index on the biological risk.
 One Gy represents 1 J/kg. This is small but the effects of this energy transfer on biological
functions is complex.
 It is the concentration of energy deposited, not the total amount deposited.
 Absorbed dose differs from exposure
 The ‘Integral Dose’ is the cumulative dose absorbed by all the tissues corresponding to
the amount of potential tissue damage. It is extrapolated from exposure as there is no
way to measure radiation absorption in the body.

Equivalent Dose: Unit= Sievert (Sv)

 Different forms of radiation have different tissue- injuring potential, some causing more
biological damage than others.
 The Equivalent Dose concept allows the biological effects of different forms of radiation
to be compared.
 Equivalent Dose is calculated by multiplying the Absorbed dose (Gy) by a weighting
factors (WR) specific to each form of radiation.
 X-Rays have a WR of 1 so the Equivalent dose and the Aborbed dose are equal.
 1sQ= 1Gy.
 The Equivalent dose is useful when assess for potential tissue injury due to highly
ionising particular such as alpha particles.

Effective Dose: Unit= Sievert (Sv)

 Various forms of radiation have different capacities for biological damage, different
tissues and organs have different sensitivities to radiation damage.
 In addition, radiation exposure is not uniform.
 Effective Dose for a particular organ is calculated by taking the Equivalent Dose and
multiplying it by a specific tissue weighting factor (WT) for that organ.
 WT relates to the organs specific susceptibility to cancer and genetic defects.
 Breast>>>Brain

Direct vs Indirect Measurements

 Patient radiation dose is most accurately evaluated by direct measurement of radiation
exposure
 For deterministic risks- best estimated by Peak Skin Dose (PSD)
 For Stochastic risks- best estimated by Effective Dose (ED)

Direct Measurements

Peak Skin Dose: Unit= Gray (Gy)

 Refers to the maximally irradiated area
 PSD is measured using thermoluminescent dosimeter
 Advantages: reliable direct measurement of points of interest. Directly attributable to
deterministic effects
 Disadvantages: Expensive and labour intensive.

Indirect Measurements:
Cumulative Air Kerma and the Interventional Reference Point (CAK)
Unit= Gray (Gy)

 This is used to asses the level of radiation present at a location.

 The ‘air kerma’ is used to measure radiation quantitiy of external radiation beams
 Air Kerma refers to the amount of energy released by the interaction of the radiation
beam with 1kg of air as the absorbing material.
 The international reference point is a constant position in space to measure air kerma.
 Air kerma accumulates at a specific point in space relative to the fluoroscopy gantry.

Dose Area Product (DAP)

Unit- Gray

 This is the air kerma multiplied by the beam corss sectional area at the point of
measurement
 CAK doesn’t take into consideration the area exposed and therefore the volume.

Fluoroscopy Time
Unites- minutes
 Time the fluoroscopy beam is activated

Documenting
The CAK, DAP and FT should eb recorded in the operative report.

Biological Effects

 X-rays have the ability to. Form ions within tissues by injected electrons from the atoms
that make up the molecules.
 This is the basic term for ionising radiation  modify chemical, physical or biological
effects of tissues.

Deterministic effects
 Tissue reactions, predictable injuries that will occur in all patients subjected to a
sufficient radiation dose.
 Once threshold has been exceeded cellular death will occur in the molecular damage
exceeds the cells own repair mechanisms.

Skin Injury
 Most common deterministic injury

Bony Injury
 Increased calclium capacity leads to greater capacity to absorb X-rays
 May manifest as osteonecrosis of superficial bones

Eye Injury
 Catracts compsomise a deterministic effect far more relevant o interventionalists than
patients.
 Permanent clouding of the eye
 Radiation can lead to direct protein and DNA damage nad indirective oxidative stress
thrgouh free radiacals.
 Usually increased incidence of posterior subcapsular cataracts
 Lens is very radiocensitive
 Thresshold of 4Gy for fractionated exposiure but single dose threshold of 0.5Gy to 1Gy
may be enough to induce cataracts.
 PSC represents the most common type of radiation-induced cataracts followed by
cortical catarcats.
 PSC is uncommon in population, difficult to detect and treatment is suboptimal

Impaired Fertility
 Deterministic effect of prolonged radiation exposure

Stochastic Effects
 Stochastic= may get cancer down the track if around a lot of radiation
 Stochastic effects of ionising radiation are chance events, with the probability of the
effect increasing with dose, but the severity of the effect is independent of the dose
received
 Less predictable
 Genetic mutations and cancer due to accumulative radiation
 Overwhelsm ability to repair DNA damage
 Tissues with rapid turn over (bone marrow and breast tissue) are more suspectible.

DNA Damage
 Stochastic effects are due to unrepairable DNA damage and consequential genetic
mutations
 Body repair mechanism and age determine whether damage leads to genetic mutations

The Linear No-threshold Theory

 Stochastic effects differ from deterministic in that they do not confirm to a dose
relationship.
 Deterministic effects do not occur below a certain threshold and therefore are a dose-
dependant
 This inlear relationship of dose and stochastic risk has lef to the concept of the linear no-
threshold theory
 Stochastic increases with dose exposure there is no threshold below which stochastic
risk is zero.
 In theory a sinle photon could ionise a critical portion of DNA, creation an oncogene.
 Forms foundation of ALARA- As Low As Reasonable Achievable.

PReducting Stochastic Risk

 Biological Effects of Ionizing Radiation VII Committee (BEIR VII) suggested an estimate of
lifetime attributable risk of acncer due to low exposure base on mathematical models.
 The lifetime fatal malignancy risk in ISU is 21%, this increases by 5% for each 1Sv of
Effective Dose Radiation.

Recommended Occupational Exposure Limits

 Based on BEIR VII Models, current IRCP reccomende dlimits are:
 Total Doby= 20 mSv/year (averaged over 5 years) and no single annual exposure of >50
mSv.
 Eye Lens= 20 mSv/year (averaged over 5 years) and no single annual exposure of >50
mSv.
 Skin= 500 mSv/year
 Hands and Feet= 500 mSV/year

Career Limits
 A 3 mSv/yeareffective dose throughout a career translates to less than 1:10000 risk of
radiation-induced cancer.
 Based on the linear, no-threshhold theory, this risk increases with dose stoaht a lifetime
cumulative expoires of 400mSV correlates to an increased cancer risk of 1:250.

Chapter 31

Radiation Exposure During EVAR

 EVAR remains the most common quintessential complex endovascular case
 Studies show one third- of EVAR patients received an Entrance Skin Dose in excess of 2Gy
 Eye, Thyroid, chest and abdomen, hands and feet are most exposed.

 More complex the procedure, the higher the associated radiation dose.
 A study should one third of repairs exceed the 2Gy skin dose deterministic threshold.
 Increased complexity associated with increased radiation dose: AAA>60mm, neck
diameter >28mm, CIA diameter >20mm and neck angulations >50.
 Have more than 2 of these related to increased radiation exposure.
 Atherectomy has the longest fluoroscopy times.

Safety

ALARA
As low as Reasonably Achievable- encompasses a philosophy of radiation safety ans is
responsibility of all operators.
Dictates exposiure to radiation should proceude sufficient benefit to the patient to offset any
risks.
Team- everyone should prepare
Culture- cultural factors impede widespread adoption of radiation safety
Leadership- good safety culture exemplified by prioriites and patterns.
Education and Training-
Distance from source
Position around the table
 The highest intensity of scatter is on the X-ray beam extrance side of the patient.
 Doses higher for primary operator
 Inverse square law is fundamental to understanding the importance of reducing
radiation dose by stepping away from the source.
Pregnancy
 Exposure in training during peak childbearing years
 Risk of intrauterine radiation on the developing foetus include: miscarriage, intrauterine
growth retardation, small head size, mental retardation, childhood cancers.
 Doses under 100mGy do not represent an increased risk to he embryo or foetus.
 A dose in excess of 20 mSv annually is set by the SCRP as the limit.

Dosimeter
 Majority are thermoliminsencent (TLD) or optically stimulated luminencence
 Worn for week/months at a time.
 They provide an estimate of radiation dose well after actual exposure they are termed
passive dosimeters.
 Location: wear on trunk to give accutae representation of whole body dose
 Combining doses from multiple sites (usually collar and trunk) will give more accurate
information regarding occupational exposure and radiation saftety behaviour.
 Number: two dosimeters is recommended. One of the torso and under lead. Under the
lead to estimate the dose to protected organs. Outside the lead to estimate unshielded
areas.
 Replacement interval: no set guidelines. Monthly measure to identify poor practice.
 Real time dosimeters are available.

Machine Controls
 Time of foot on pedal greatest determinant of radiation exposure.
 Eseential to minimise exposure and use of fluro
 Removal of wries and catheters using short taps to spot fluoroscopy.

Automatic Dose Settings

 Modern machines have Automatic Brightness Control optimises image quality by
automatically increasing radiation dose.
Fluoroscopy and Pulse Rate
 Created either continuous or pulsed
 Continuous is associated with blurred images
 Pulsed counteracts these movements and reduces blurring whilst reducing radiation
exposure.
 Pulse rates are 30, 15,7.5, 4, 2 pulses per second.
 Human eye can only register 12 images per second.
 Decreasing pulse rate decreases fluoroscopy dose.

DSA
 High radiation doses
 50-80% of radiation in EVAR and FEVAR
 DSA associated with 6-10 times higher the dose compared to fluoroscopy
 DSA should be minimised

Collimation
 Filters within the X-Ray source to reduce the radiation field size to the minimal required
area of interest.
 Shaping the beam and absorbing low-energy photons in useful in image generation-
produces a sharper image and reduces radiation exposure.
 Increasing horizontal and vertical collimation independently of 0 to 10cm, reduce scatter
to the operator, assistance and anaesthetist by 86%.

Magnification
 Image intensifiers come in a range of sizes
 Field of views(FOV)
 By magnifying and decreasing the FOV, the spatial resolution is doubled. Only a quarter
of the input II is being irradiated as the area is proportional to the square of the FOV.
 In general, the smaller the FOV, the larger the magnification and the higher the patient
dose.
 During magnification, collimation is automatically applied  reduces scatter  a smaller
FOV increases CAK but decreases DAP increasing the risk of deterministic effects to the
patient.

Imaging Chain Geometry

 Refers to the combined linear arrangement of the X-ray source to paitnet and the patient
to detector.
 Btoh have independent influcen on the scatter.
 X ray is under aptient to make sure maximum scatter is dispersed under the table
 Distance between X-ray and patient is set by table height
 Collimation and magnification- balance between radiation to the patient and doctor.
 Detector as close to the apteint as possible- large distances cause increase in dispersion
of the X-ray beam reduction in signal reaching the II

C- Arm Angulation
 Important to avoid steep C-Arm angulation
 1. Creates more scatter
 2. Requires more radiations
 3. Places the X-ray closer to the skin
Flat panel Detectors
 Flat panel detectors reduce radiation dose.
 They have high sensitivity to X-rays, limited distortion and high uniformity

Fixed vs Mobile C_Arms

 C-arms are shown to have a reduced overall radiation dose of 3.5 times lower than fixed
systems.
 However, C-Arm are inferior capabilities

Operator-Controlled Imaging
 Helps to decrease any misunderstanding between surgeon and radiographer
 If OCI is unavailable, improving communication is necessary
 Ones study showed decrease in fluoroscopy time and radiation exposure.

Advanced Dose- Reduction Software

 Modern imaging equiptment produces excellent images
 System include; machine controls, image processing algorithms and hardware
configurations to reduce entrance dose
 All of these help to improve images and decrease radiation exposure.

Shielding
 Shielding is built into the walls
 Equipment mounted lead, ceiling mounted acrylic, floor supported mobile shields and
leaded personal equipment.
 The patient is the main source of scatter, most shielding is designed to act as a barrier
between patient and operator.

Personal Lead Garments

 Usually require a minimum of 0.35mm of lead at the front and 0.25 at the back
 Issues regarding the MSK ailments that come with long-term lead wearing.
 Aprons can also be made of antimony and bismuth to be lighter
 Guideline is to have your own lead and maintain it. Should be made from lead that
provides 0.5mmPb LE from each posteiror axillary line.

Eye Glasses
 Dramatically reduce the eye dose by. A factor of 5-10
 Wide variation of radiation attenuation in glasses reported with same lead equivalence
and lens thickness.
 Radiation incidence angle and frame fitting can play a role in proportion of radation.
 Recommended that it is worn from 0.75mmPb LE leaded glass in a well fitted frame with
no gaps at the nose and cheek.
Thyroid
 0.5mmPb shield is recommended
 Substantially reduces thyroid radiation dose

Hats
 Scatter is lowest at the head
 Skull attenuates 40% of scatter
 Recent studies shows head exposure is almost 10 times higher than the whole body
exposure.

Hands and gloves

 Hands recive more Xrays than other parts of the body
 Correlation between DAP and eye and dinfer doses
 Lead gloves hould be avoided as they can paradoxically lead to higher handdoses.
 If within the beam, can attenuate radiation and increase forward and back scatter
indefinitely.

Ceiling Mount Shielding.

 Shown to have protection to the head and neck.

Leg and foot shielding

 Highest scatter is under the table where the beamenters the patient
 Lead skirt reduced dose by 5-50 percent.
 Majoirty if SNA damage in the long bones of the legs

Drapes
 Biusmuth-barium drapes reduce scatter to operator.
 0.4-0.8mm Pb