7 X-ray diagnostics 7.5 X-ray image intensifiers As opposed to the x-ray exposure, which achieved a useful technical level rela- lively soon after the discovery of x-rays, x-ray fluoroscopy remained virtually unchanged right up until the fifties: the radiologist viewed the fluoroscopic sereen after suitable dark-adaptation of his eyes. For normal dose rates in fluoroscopy, the luminance of the screen is in the pure rod vision range, ie. the viewing conditions are poor (sce chapter 1). The mismatch between the flow of x-ray quanta supplied (behind the patient) and the flow of visually recorded information had been recognized for a long time: an effective remedy was not found, however, until the introduction of the clectron-optical x-ray image intensifier tube in 1948 [7.47] In the early years of x-ray image intensification the bright, but extremely scaled- down output image of the x-ray image intensifier was viewed with an optical magnifier. Then, in the sixties, image intensifier television became established which brought further substantial advantages compared to viewing with optics magnifying, Modern x-ray image intensifiers are manufactured with an input field diameter between 15 and $7.cm. Fig, 7.82 shows a modern 40cm x-ray image intensifier. Here the x-ray input window is made out of a 1.2 mm thick aluminum sheet, the tube housing out of stainless steel, and the insulating ring surrounding the output window of aluminum oxide ceramic material. Fig. 7.82 X-ray image intensifier tube with 40 cm input diameter. By changing the focusing volt- ages whilst retaining the anode voltage of 35 KY, it is possible to switch to input field diameters of 28 cm, 20 cm and 14 cm. Tn this process the conversion factor decreases (ie. the output screen luminance relative to the dose rate in the input plane); the reso- lution increases 318.X-ray image intensities In order to be able to use fluoroscopy with bright-adapted cyes even without x-ray television (for the simpler types of examination equipment or in restricting circumstances), an image intensifier of a flat construction was developed in 1980, producing an output image having true dimensions (see section 7.1.5.9). 7.1.5.1 Principles of operation of the x-ray image intensifier ‘An x-ray image intensifier (x-ray 11, is a vacuum tube in which an x-ray image is transformed into a visible inmage of high luminance. Fig. 7.83 shows a longitu- dinal section through an x-ray LI. tube in which only the essential components are depicted. It works as follows: ‘The x radiation which has been spatially modulated by the object under exami- nation penetrates the radiolucent input window of the tube and strikes an x-ray fluorescent screen. This converts the x-ray image into an optical image. A very thin photosensitive layer, the photocathode, is in optical contact with the fluores- cent screen. This photocathode transforms the brightness distribution of the optical image on the screen into an electron flux density distribution. In the half-space in front of the photocathode, the photoelectrons are emitted in all directions. The x-ray screen and the photocathode are situated on a curved base which for electron-optical reasons has approximately the shape of a spheri- cal dish. Electron trajectories Electrodes for electron optics incident reradiation we —> ee Output fluorescent —_ screen _—— Anode voltage +2510 +35 KV —— Vacuum vessel Input fluorescent coroan » Photocathode Fig. 7.83 Longitudinal cross-section through an x-ray image intensifier (schematic) 3197 X-ray diagnostics As shown in Fig. 7.83, the electrons emitted in various directions from a point in the photocathode are deflected by the electrical field in the interior of the image intensifier in such a way that together their trajectories form a lohar bundle which attains its greatest thickness near the photocathode and becomes progressively narrower towards the anode. At the output fluorescent screen, the electron trajectories come together again at one point, the image point. During their motion in the externally applied electric field, the electrons pick up kinetic energy. After traversing a potential difference of about 25 to 35 kV, the energy of an electron is sufficient to generate roughly a thousand light quanta in the output screen. The electric field in the x-ray image intensifier has a similar effect on the electrons as a focussing lens has for light rays: there arises an inverted, in this case substantially reduced, image. Since all the photoelectrons emitted into the half- space are caught by the electron lens, electron-optical imaging is very ‘efficient’. The high luminance at the output fluorescent screen is achieved, on the one hand, by the acceleration of the photoelectrons, and, on the other hand, by the concentration of the electron flux from the large photocathode area onto the very much smaller output screen area. The total luminous flux is not increased by this second effect, but the luminance is. The small, bright output image is very well suited for image transfer to the connected systems (television camera, single-frame or cine camera), because further recording can now take place through lenses with short focal lengths and wide apertures (see section 7.1.58). A numerical example will now be given for the flux density of the respective information-carrying quanta in the various transformation stages. The example uses the dose rate of 0.2 wGy/s (20 R/s) at the image intensifier input, this being normal for x-ray fluoroscopy. With a radiation quality corresponding to a half value thickness of 7 mm aluminum and given this dose rate, roughly 5x 10% x-ray quanta per square centimeter and second arrive at the image inten- sifier input. In the input window there is a loss due to absorption of the order of 10%, The absorption in the x-ray fluorescent screen which can be used for generating the image (‘eflective’ absorption) depends on the material of the screen and the thickness of the coating as well as on the radiation quality. For screens of a more recent design made from sodium-doped cesium iodide, onc can assume an effective absorption level of 50 tu 70%. Thus, for the actual image intensification only a flux density of about 2x 10° x-ray quanta per square centimeter and second remains available. In the x-ray screen every effec- tively absorbed x-ray quantum generates several thousand light quanta, of which, however, only a fraction reach the photocathode and there lead to the emission of photoelectrons with a quantum yield of a few percent. In total one obtains about 250 photoelectrons per absorbed x-ray quantum, ie. roughly 9x10" electrons per square centimeter and second. Each electron accelerated, eg. to 25 KV, finally produces about 1000 light quanta in the output screen. 320X-ray image intensities Thus, one obtains a photon flux of 5x 10! per square centimeter of input area and second, This numerical example shows that the flux of the quanta transmitting the image information is clearly smallest at one particular part of the chain, namely when the effective absorption of the x-ray quanta occurs in the x-ray fluorescent screen. The following considerations show that this so-called quantum bottle- neck acquires fundamental importance with respect to the achievable image quality. If, for the resolving power of an image intensifier television combination, one assumes a value of 2.5 line pairs per millimeter — in the input plane — then one obtains 2500 resolution elements per square centimeter of input area. The integration time of the entire transmission chain (including the eye) is about 0.2. The above-mentioned flux density effectively contributing to the image transformation (in the image intensifier input plane) of 2x 10° x-ray quanta per square centimeter and second is thus distributed over 2500 spatial and five temporal resolution elements, with the result that on average only 16 x-ray quanta contribute effectively to each spatiotemporal resolution element of the fluoroscopic image. From statistics one learns that the frequency of occurrence of statistically inde- pendent events — in this case the incidence of x-ray quanta — forms a Poisson distribution. If N is the mean value of this distribution, then the standard Number of quanta por om? and ¢ = : ‘0° z ae zs € | 2 8 . sf Ct Grae = = g 23 2 & £2 | 38 a Pee £ 8 | 82 a mee © we Flow of image information —= Fig. 7.84 Flux densities of the information-carrying quanta in the various transformation stages of the x-ray image intensifier (x-ray 1.1} for fluoroscopy 3247_X-ray diagnostics deviation ¢ is equal to |/N (mean fluctuation). In 68% of all cases, the number of events lies within the frequency range between N—|/N and N+)/N, and in 32% of all cases outside it. In the numerical example, N=16 and the standard deviation //N=4, ic. a full quarter of the mean value. This numerical example illustrates the statistical graininess of the x-ray fluoroscopic image known as quantum noise. As already mentioned, this is caused by the relatively low number of effectively absorbed X-ray quanta. At the same time it becomes clear that in the case of less good spatial or temporal image resolution (the latter e.g, due to a ‘slow’ television camera tube) the impression with respect tv uvise is more favorable, i.e. the picture is steadier, A more detailed discussion of quantum noise can be found in [7.48]. 7.1.5.2 X-ray fluorescent screens (input screens) The properties of input phosphors have a crucial influence on the quality of the image transmission of the x-ray image intensifier as a whole. The input phosphor determines to what extent the x-ray quantum flux, which for reasons of radiation protection and often also for technical reasons (see section 7.1.1) is kept small, can be exploited for the generation of images. A compromise must be found between the conflicting requirements for a higher absorption of quanta (large thickness of the x-ray fluorescent layer) and for high resolution ~ or more generally: high MTF values ~ (thin fluorescent layer). Since the resolution limit is more immediately noticeable than a little more or a little Csedge | Mass attenuation coefficient w/o Relative spectral distribution ofthe radiation 10 . _2nS (60%) Cas 40%) ~~~ 20 30 40 50 80 kev 70 Xray quantum enetgy —= Fig. 7.85 Mass attenuation coefficient 4/g of ZnCdS (dashed line) and of CsI as a function of quantum energy. For comparison: spectrum of the x sadiation behind a patient sub- mitted to fluoroscopy, simulated by a 15 cm water layer, at 70 kV x-ray tube voltage. 322X-ray fluorescent screens less quantum noise, one has to consciously resist the temptation to give prefer- ence to the resolution at the expense of the absorption of the quanta. The aim must be the optimization of the diagnostically significant image quality at the end of the entire information chain, and, moreover, in conditions corre- sponding to those found in clinical practice with respect to focal spot size of the x-ray tube, dose rate, radiation quality, organ motion, geometric magnifi- cation, lag of the television camera tube, and MTF of the connected systems, to mention just the most important factors. In the case of the x-ray-fluorescent material zinc cadmium sulfide (ZnCdS: Ag) generally used for input screens up to the beginning of the seventies, the above- mentioned compromise was a very unsatisfactory one. It was not until the introduction of the new x-ray-fluorescent material cesium iodide (CsI:Na) that the breakthrough was made to the high image quality standard usual today. The x-ray fluorescent material Csl:Na combines several desirable properties in an almost ideal way: > favoruble absorption values for x-ray quantum energies above the K absorp- tion edges of Cs (33 keV) and I (36 keV) (Fig. 7.85), = good spectral matching to SbCs3 photocathodes (Fig. 7.86), chemical com- patibility with this photocathode, = good vacuum properties (withstands the degassing temperature), = sereen manufacture by vapor deposition, producing > packing density almost equal to that of the bulk material (in contrast to screens made by sedimentation with a substantially lower packing density), and © good adhesion of the vapor-deposited screen to aluminum sheet ~ thus ease of manufacturing any shape of screen to within narrow tolerances (important for the electron optics). Relative units 10: 08: 06: 04: SoCs; 02 S60 400 500 600 nm 700 Wavelengtn —=— Fig, 7.86 Spectral matching of ZnCdS:Ag and of CsI:Na to the sensitivity distribution of the cesium-antimony photocathode ae7_X-ray diagnostics Fig. 7.87 Picture of the broken edge of a CsI x-ray screen taken with a scanning electron micro- scope Top: Surface of the x-ray screen Middle: Broken edge of the CsI crystallites (height about 150 1m) Bottom: Chemically rough- ened aluminum substrate If the vapor deposition process is carried out in a suitable way, the screen consists of continuous crystallites partially separated by fissures which are per- pendicular to the substrate and help to conduct the light in the desired direction (Fig. 787), With the CsI screen, the long-standing wish for a screen with a high quantum yield and a high resolving power was largely realised. 7.1.5.3 Photocathode The photocathode in the x-ray image intensifier is a transparent cathode. It is made out of antimony and one or more alkali metals, preferably cesium, which are deposited simultaneously or sequentially by vaporization in a thin layer (about 10 to 30 nm) [7.49]. Its substrate is the x-ray screen, itself, with or without a transparent intermediate layer. The spatial distribution of the photoelectron emission is thus a ‘contact print’ of the instantancous distribution of luminescent light in the x-ray screen, The life of the photocathode ~ and thus of the x-ray image intensifier tube is many years at room temperature and with a good vacuum (about 10° ® mbar; if necessary, it must be regettered). Long-term exposure to tempera- tures above approximately 35 °C has an adverse effect on its life 7.15.4 Electron-optical imaging The electro-optical system in the x-ray image intensifier (x-ray 1.1) is intended to accelerate the photoelectrons that emerge from each point on the photocath- 324Photocathode - Electron-optical imaging ode in all directions into the half-space in front of it and to form as point-like an image of these as possible on the output screen. This is only possible to a limited extent, especially as the photoelectrons, apart from the distribution of directions, also have an initial energy between 0 and approximately 1.3 eV. This is small in comparison to the acceleration voltage of 25 to 35 kV, but it is not negligible, Furthermore, the pincushion-shaped distortion must be kept small, and the depth of the x-ray LI. tube should be as short as possible. And finally, for further imaging on to the connected cameras a planar output image is required, unless one decides to let the output image be formed on the hollow-ground inner surface of a fiber optic plate coated with fluorescent material and to level it out with its flat-ground outer surface. ‘The imaging takes place by means of an axially symmetric electrostatic potential distribution which is produced by the photocathode, several auxiliary electrodes Fig. 7.88 Numerically computed equipotential surfaces and electron trajectories in the meridian plane of an x-ray image intensifier with two focusing electrodes; initial energy of the photoelectrons 0.5 eV 3257 X-ray diagnosties and the anode with the output screen. The calculation of the potential distribu- tion and the electron trajectories for the various initial conditions requires a large computer system [7.50]. Favorable imaging properties result if the pho- tocathode has the shape of a hyperboloid of rotation, whose contour, however, only deviates slightly from that of a spherical cap. In this way a good flattening out of the output image is achieved. Fig. 7.88 shows such a computed potential distribution with a few electron trajectories. Deviations from the axially symmetric potential distribution lead to imaging errors (astigmatism). Dimensional stability of the electrodes is therefore impor- tant, and for large diameters this can only be maintained with a great deal of effort. Fig. 7.89 shows two interlocking cylindrical electrodes made of stainless steel which have several rings to make them stiffer. Electron-optical imaging is very sensitive to external electric and magnetic fields. In the protective casing a magnetic shield is therefore provided, which is made out of highly permeable sheet-metal and sealed as well as possible, This at least largely excludes the geomagnetic field, Nonetheless, it is advisable that coils, magnets and larger electrical alternating fields (such as those which occur for example near electric cables carrying a heavy load) be kept away from the image intensifier. The majority of modern x-ray image intensifiers, especially the large-format ones, offer the possibility of electron-optical format switching (‘zoom’). In this process the anode voltage remains constant, but by changing the focussing voltages only a (concentric) part of the input field is imaged on the whole output screen, ie. the electron-optical minification is lessened. Because of this, the image resolution is increased; however, the conversion factor is reduced (see sections 7.1.5.6 and 7.1.5.7). Format switching is above all desirable so that the smallest possible image field for the particular radiological task can be projected on to the film or the television monitor so that it fills the format, Fig. 7.89 Two concentric interlocking cy- lindrical focusing electrodes from a 27 0m x-ray image intensifier 326Output sereens » Gain factor 7155 Output screens X-ray image intensifier output phospors consist of a fluorescent layer (generally ZnCdS:Ag) just a few micrometers thick and as uniform as possible, on a glass base which may simultaneously by the image output window of the vacu- um envelope. Feedback of light to the photocathode is prevented by the fact that the surface of the fluorescent layer is covered with an aluminum skin which is opaque to light but allows the high-energy electrons through. It also serves as an equipotential surface and as an electrical connection to the anode. Multiple reflection in the output screen base causes stray light which deteriorates the image contrast. The contrast can be improved by using tinted glass as the screen base; the useful light, which only passes through the base once, is attenuated less in the glass than the stray light, which has to go through the glass base at least three times, An expensive, but effective measure for selective attenuation of the stray light is the use of a fiber-optic disk for the output screen base. There is a new development which enables the interference light to be suppressed without the concomitant attenuation of the useful light: one makes the glass base of the output screen roughly as thick as its radius. Then the totally reflected part of the stray light - which makes by far the biggest contribution — is not directed back towards the fluorescent layer but to the blackened edge of the sereen base where it is absorbed. 7.1.56 Total gain factor, conversion factor Avoiding to the above estimates (sce also Tig. 7.84), one obtains about 100 light quanta in the output half-space for every light quantum emitted by the x-ray screen into the photocathode half-space. This factor is called the lumen gain, although the term is slightly dubious because of the different luminescence spectra. The luminance (unit: cd/m?) is increased additionally by the factor corresponding to the ratio of the areas of the input and output screens, i.e. for standard x-ray image intensifiers by a factor of 50 to 200, so that there results a total luminance gain of about 10°. It is more useful to give the conversion factor G, (old unit: ed/m?/mR/s; new unit: ed/m?/nGy/s), which states the ratio of the luminance obtained at the output phosphor to the dose rate of the incident radiation (for standardized ICRU! radiation quality, ic. 20 mm Al-prefiltration and 7 mm aluminum first half value thickness). "International Commission on Radiological Units and Measurements (se also DIN 6814 Part 2) 3277_X-ray diagnostics 7.15.7 Resolving power, modulation transfer function (MTF) The resolving power of an x-ray image intensifier is determined by the two soreeny and the quality of the electron-optical imaging, in particular the electron- optical minification ratio, In x-ray image intensifiers with an input field which can be switched electron-optically, ie, with a variable image ratio, the resolving power increases with the reduction of the input field used. Example: In Fig. 7.90, the MTF of a 27cm x-ray image intensifier with full input field is compared to the MTF with the input field switched to a diameter of 17 om. Experience shows that the limit of resolution corresponds to the spatial frequency at which the MTF value has dropped to about 0.04; here this is slightly over four line pairs/mm for the full input field, and about five lines pairs/mm for the 17cm input field. As recently as 1970, a resolution of two line pairs/mm could only be achieved with difficulty (7.51, 7.52]. 7.1.5.8 Further processing of the x-ray image intensifier outpu age The output image of the x-ray image intensifier is transmitted with special large-aperture lenses in a tandem optical arrangement. By this is meant an ar- rangement consisting of two lenses, whereby the object (x-ray LI. output phos- phor) lies in the focal plane of the first (the so-called collimator) lens, whilst Contrast transfer factor 10 05: 02. 17 om diameter ot : 27 om ciameter 005; 0.02: oan: 0 1 2 3 Fig. 7.90 Modulation transfer function of a 27 cm x-ray image intensifier for the full input field, and an input field switched electron-optically to 17 cm respectively Vm 6 4 5 Spatial frequency 328Resolving power, MTF - Further processing of the output image the image (on the film or in the television camera) is created in the focal plane of the second (the so-called camera) lens. In between the two lenses of the tandem arrangement, the light rays run parallel, The lenses can therefore be pulled apait and cau each be focussed individually. The lateral magnification is equal to the ratio of the focal lengths of the two lenses, The relatively narrow emission spectrum of the output phosphor (e.g. emission maximum of 535 nm, width about 100 nm) permits aperture ratios up to 0.75 for a focal length of 50mm. Because of the image quality achieved nowadays with x-ray image intensifiers, indirect radiography (using a film format of 100 mm x 100 mm), which allows the more economical use of dose and film, is becoming more and more widely used. Rapid processes, e.g. in cardiology, are investigated with the aid of x-ray cine. Since both procedures are always linked to fluoroscopy, an image distribu- tor is used, which guides the light beam to the desired systems by means of mirrors (in certain circumstances semi-transparent ones for simultaneous televi- sion observation). Because the rays run parallel behind the collimator lens the position of the deflecting mirror and the respective camera Jens 1s not critical Fig. 7.92 shows schematically a 3-channel image distributor. Whereas in the past the ‘indirect’ radiographs taken through the image intensi- fier were only accepted out of necessity (because of their poorer image quality) when it was important to have very short exposure times and a rapid image sequence as in cardiology, the indirect images exposed with present-day high- Colimator lens Semitransparent mirror for light spliting X-ray LI. output fluorescent image Channel t Channel 2 Camera lens 2 Fig. 7.91 Tandem optical arrangement with 2-channel image distributor 3297 X-ray diagnostics +00 mm camera Beam-spiting mitrar TWeamera i control unt Xeray image intensifier a EEX a bSsy CS Cie camera Monitor Fig. 7.92 Schematic view of an x-ray unit with a 3-channel image distributor. The semitranspar- ent image-distributor mirror in the parallel path of the rays allows simultaneous televi- ion observation during cine or single frame fluorography. resolution image intensifiers are definitely comparable in image quality with conventional radiographs. The dose requirement for an indirect image at about 75 wR (0.66 Gy) is still considerably less than that for a full-size radiograph with rare-carth screens. Thus it is also possible tu lave very short exposure times to avoid kinetic blurring. 7.1.5.9 Panel-type image intensifiers In contrast to the x-ray image intensifiers described up to now, the panel-type image intensifier produces a non-inverted true-size image. In a panel-type image intensifier the electron-optical imaging discussed in section 7.1.54 is replaced by so-called proximity focussing of the photoelectrons (Fig. 7.93). Here the photocathodes and the fluorescent screens are situated opposite to each other in parallel planes with a voltage difference of about 15 kV, with the result that a homogeneous electric field is created in the space between them. In this space the photoelectrons describe parabolic trajectories. Because of the small distance between the plates and the correspondingly high field strength, however, the ‘opening’ of the parabolic trajectories remains so small, i. the bundle of electrons emerging from a point on the photocathode is so narrow, that the resulting 1:1 imaging is still sufficiently sharp. In order to achieve the roughly 3000-fold intensification of luminance required, two such intensification stages are necessary. A transparent support transfers the image of the intermediate screen to photocathode 2, and the imaging by proximity focussing is repeated. Nonetheless, the panel-type image intensifier 330,Panel-type image intensifiers - X-ray television 30K “15K cathode we a a Z PM X radiation zg : DPW a bc Fig. 7.93, Pig. 7.94 Construction of a 1:1 recording ra- KLINOGRAPH 4 examination unit with tio, two-stage x-ray image intensifier the PLANICON. Panel-type x-ray image of flat design. Input screen (2), inter- intensifier mediate sereon (b), and output The round image field has a diameter of screen (c) are flat, but otherwise 20m. similarly constructed as in a con- ventional (minifying) x-ray LL attains a resolving power of about 2 line pairs/mm, which roughly corresponds to that of x-ray television. Imaging in a panel-type image intensifier is practically inertia-free. Fig. 7.94 shows an examination unit with a panel-type image intensi- fier. 7.1.6 X-ray television 7.1.6.1 Television camera tubes (pick-up tube) The television camera tubes which are used to transform the light from the x-ray image intensifier into an electric signal current are all of the Vidicon type. Thus, the construction and operation of the Vidicon will be described below as being representative for all camera tubes. Tubes like PLUMBICON, SATICON, PASECON, NEWICON and VIDICON (or HIVICON) differ from each other only in the type and the construction of their photoconductive layer (photo-semiconductor, hereafter called ‘the layer’ for short). 331