DEPARTMENT OF PHYSICS, UNIVERSITY OF JAFFNA, JAFFNA

PHY321GE2: MEDICAL PHYSICS

MEDICAL IMAGING
Dr. Thirunavukkarasu Pathmathas
[PhD (Physics), (Cape Town)], [MSc (Medical Physics), (Peradeniya)],
[ICTP Dip (Theoretical Physics), (Trieste)], [BSc Hons (Physics), (Jaffna)]
Senior Lecturer in Physics, Department of Physics, University of Jaffna,
October 9, 2020

SYLLABUS
Medical imaging: Principles of image formation and quality, films and screens, digital
imaging, image reconstruction with back projection, X- ray, Computed Tomography (CT)
and image processing, radiography (mammography and Fluoroscopy), Principles of Magnetic
Resonance Imaging (MRI),Mapping and applications, Medical transducers, Principle and
practice of Ultrasound Imaging.

REFERENCES
(1) The Essential Physics of Medical Imaging by Jerrold T. Bushberg and J. Anthony Seibert
(2) Physics of Radiology by Antony Brinton Wolbarst.
(3) Fundamental Physics of Radiology by W.J.Meredith and J.B.Massey.
(4) The physics of medical imaging by Steve Webb
(5) The Physical Principles of Medical Imaging by Perry
(6) Fundamentals of Medical Imaging by Paul Suetens.
(7) Physics in Modern Medicine by Suzanne Amador Kane.

Introduction to Medical Imaging

Medical Imaging is useful to investigate and diagnose the disease. In diagnostic radiology,
the electromagnetic spectrum outside the visible light region is used for medical imaging,
including X-rays in mammography and computed tomography (CT); radiofrequency (RF) in
magnetic resonance imaging (MRI), gamma rays in positron emission tomography (PET),
and in nuclear medicine. Mechanical energy, in the form of high-frequency sound waves, is
used in ultrasound imaging.

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Medical imaging requires that the energy used to penetrate the body’s tissues also interacts
(e.g., absorption or scattering) with those tissues. In the medical imaging techniques used in
radiology, the energy used to produce the image must be capable of penetrating tissues to
contain any useful information regarding the internal anatomy. Otherwise, not be possible to
construct an image of the anatomy using that information.

The Modalities
Different types of medical images can be made by varying the types of energies and the
acquisition technology used. The different modes of making images are referred to as
modalities. Each modality has its own applications in medicine.

Radiography
Radiography, transmission imaging modality, is performed with an X-ray source on one side
of the patient and a (typically flat) X-ray detector on the other side. A short-duration
(typically less than ½ second) pulse of X-rays is emitted by the X-ray tube, a large fraction of
the X-rays interact in the patient, and some of the X-rays pass through the patient and reach
the detector, where a radiographic image is formed.
The homogeneous distribution of X-rays that enters the patient is modified by the degree to
which the X-rays are removed from the beam (i.e., attenuated) by scattering and absorption
within the tissues. The attenuation properties of tissues such as bone, soft tissue, and air
inside the patient are very different, resulting in a heterogeneous distribution of X-rays that
emerges from the patient. The radiographic image is a picture of this X-ray distribution.
The detector used in radiography can be photographic film (e.g., screen-film radiography) or
an electronic detector system (i.e., digital radiography).

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Projection imaging refers to the case when each point on the image corresponds to
information along a straight-line trajectory through the patient. Radiography is also a
projection imaging modality. Radiographic images are useful for a very wide range of
medical indications, including the diagnosis of broken bones, lung cancer, cardiovascular
disorders, etc.

Fluoroscopy
Fluoroscopy refers to the continuous acquisition of a sequence of X-ray images over time,
essentially a real-time X-ray movie of the patient. It is a transmission projection imaging
modality, and is, in essence, just real-time radiography.
Fluoroscopic systems use X-ray detector systems capable of producing images in rapid
temporal sequence. Fluoroscopy is used for positioning catheters in arteries, visualizing
contrast agents in the gastrointestinal tract (GIT), and for other medical applications such as
invasive therapeutic procedures where real-time image feedback is necessary. It is also used
to make X-ray movies of anatomic motion (heart).

Mammography
Mammography is a specialized X-ray projection imaging technique useful for detecting
breast anomalies such as masses and calcifications. Dedicated mammography equipment uses
low X-ray energies to produce breast images of high quality and low X-ray dose. The digital
mammogram in (A) shows glandular and fatty tissues, the skin line of the breast, and a
possibly cancerous mass (arrow). In projection mammography, superposition of tissues at
different depths can mask the features of malignancy or cause artifacts that mimic tumours.

The digital tomosynthesis (X-rays of one object are taken from discrete number angles)
image in (B) shows a mid-depth synthesized tomogram. The cross sectional images are used

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to reconstruct 3D images of the object being imaged. By reducing overlying and underlying
anatomy with the tomosynthesis, the suspected mass in the breast is clearly depicted with a
speculated appearance, indicative of cancer.
Tomosynthesis differs from computed tomography because the range of angles used is less
than 360˚, which is used in CT.
X-ray mammography currently is the procedure of choice for screening and early detection
of breast cancer because of high sensitivity, excellent benefit-to-risk ratio and low cost.

Computed Tomography
CT images are produced by passing X-rays through the body at a large number of angles, by
rotating the X-ray tube around the body. A detector array, opposite the X-ray source, collects
the transmission projection data. The numerous data points collected in this manner are
synthesized by a computer into tomographic images of the patient. CT is a transmission
technique that results in images of individual slabs of tissue in the patient.
The advantage of CT over radiography is its ability to display three-dimensional (3D) slices
of the anatomy of interest, eliminating the superposition of anatomical structures and thereby
presenting an unobstructed view of detailed anatomy to the physician.

Modern CT scanners can acquire 5mm-thick tomographic images along a few cm length of
the patient in 5 seconds, and reveal the presence of cancer, ruptured disks, subdural
hematomas, aneurysms, and much other pathology.

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Plain radiography (X-ray projection radiography)

In standard plain radiography, a uniform X-ray shadow producing by the body is captured on
film. The X-ray image is a projection of attenuating properties of all the bones or organs
along the path of X-rays more effectively than the surrounding tissue. It is a two-dimensional
projection of three dimensional distributions of the X-ray attenuating properties of tissue.
Radiographic imaging may be thought of as involving four separate processes.

(i) Generation of relatively uniform beam of penetrating X-rays: Theses emanate

from a point and travel in straight lines which, as they reach the patient, diverge
only slowly.
(ii) Differential attenuation of the beam by the tissues and organs being imaged:
Different parts of the patient body absorb and scatter different amounts of energy,
and thereby sculpt the primary X-ray image out of the formerly uniform beam. A
contrast medium is also used to enable some organs to form an image.
(iii) Detection of the radiation exiting the body by the film in a cassette: Any spatial
non uniformity in the immerging beam recorded on film are revealed, on its
development, as spatially varying shades of gray which forms the final visual X
ray image.
(iv) Analysis and interpretation of the image: This depends on the quality of the final
image, the viewing conditions, and skills of the physician.

X-ray Production, X-ray Tubes, and X-ray Generators

X-rays are produced when highly energetic electrons interact with matter, converting some of
their kinetic energy into electromagnetic radiation. A device that produces X-rays in the
diagnostic energy range typically contains an electron source, an evacuated path for electron
acceleration, a target electrode, and an external power source to provide a high voltage
(potential difference) to accelerate the electrons.
(i) Specifically, the X-ray tube insert contains the electron source and target within an
evacuated glass or metal envelope; the tube housing provides
(a) protective radiation shielding and
(b) cools the X-ray tube insert;
(ii) The X-ray generator supplies the voltage to accelerate the electrons;

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(iii) Collimators define the size and shape of the X-ray field incident on the patient.
(iv) The generator also permits control of the X-ray beam characteristics through the
selection of voltage (The amount of energy carried by each electron is determined by the
voltage or KV, between the anode and cathode), current (The number of electrons which
pass from the cathode to the anode represents the tube current and is measured in
milliampere), and exposure time. These components work in concert to create a beam of
X-ray photons of well-defined intensity, penetrability, and spatial distribution.

Bremsstrahlung Spectrum

For diagnostic radiology, a large electric potential difference of 20 to 150 kV is applied

between two electrodes in the vacuum. As electrons from the cathode travel to the anode,
they are accelerated by the voltage between the electrodes and attain kinetic energies equal to
the product of the electrical charge and potential difference.

On impact with the target, the kinetic energy of the electrons is converted to other forms of
energy. The vast majority of interactions are collisional, whereby energy exchanges with
electrons in the target give rise to heat. A small fraction of the accelerated electrons comes
within the proximity of an atomic nucleus and is influenced by its positive electric field.
Electrical (Coulombic) forces attract and decelerate an electron and change its direction,
causing a loss of kinetic energy, which is emitted as an X-ray photon of equal energy (i.e.,
bremsstrahlung radiation).
The amount of energy lost by the electron and thus the energy of the resulting X-ray are
determined by the distance between the incident electron and the target nucleus, since the

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Coulombic) force is proportional to the inverse of the square of the distance. At relatively
large distances from the nucleus, the Columbic attraction is weak; these encounters produce
low X-ray energies (electron no. 3). At closer interaction distances, the force acting on the
electron increases, causing a greater deceleration; these encounters produce higher X-ray
energies (electron no. 2). A nearly direct impact of an electron with the target nucleus results
in loss of nearly all of the electron’s kinetic energy (electron no. 1). In this rare situation, the
highest X-ray energies are produced.

Characteristic X-ray Spectrum

In addition to the continuous bremsstrahlung X-ray spectrum, discrete X-ray energy peaks
called “characteristic radiation” can be present, depending on the elemental composition of
the target electrode and the applied X-ray tube voltage.

Generation of a characteristic X-ray in a target atom occurs in the following sequence:

(i) The incident electron interacts with the K-shell electron via a repulsive electrical
force.
(ii) The K-shell electron is removed (only if the energy of the incident electron is greater
than the K-shell binding energy), leaving a vacancy in the K-shell.
(iii)An electron from the adjacent L-shell (or possibly a different shell) fills the vacancy.

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 (iv) A 𝐾𝛼 characteristic X-ray photon is emitted with energy equal to the difference
between the binding energies of the two shells. In this case, a 59.3-keV photon is
emitted.

𝐾𝛽 refers to an electron transition from the M shell to the K shell. A 𝐾𝛽 X-ray is more
energetic than a 𝐾𝛼 X-ray. Characteristic X-rays other than those generated by K-shell
transitions are too low in energy for any useful contributions to the image formation process
and are undesirable for diagnostic imaging.

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Interactions of X-rays with the body
In order to produce images with high SNR (signal to noise ratio) and high CNR (contrast to
noise ratio), three basic criteria should be satisfied:
1. sufficient X-rays must be transmitted through the body for a high SNR,
2. X-ray absorption must be sufficiently different between different tissue-types in order to
produce high contrast, and
3. there must be a method for removing X-rays which are scattered through unknown angles
as they pass through the body.

X-rays are ionizing waves. Such photons are able to ionize an atom, i.e., to release an
electron from the atom. Photons with energy less than 13.6 eV are nonionizing. These
photons cannot eject an electron from its atom, but are only able to raise it to a higher energy
shell, a process called excitation. Ionizing photons can interact with matter in different ways.

1. The energy of X-ray photons can be absorbed by an atom and immediately released again
in the form of a new photon with the same energy but traveling in a different direction.
This nonionizing process is called Rayleigh scattering or coherent scattering and occurs
mainly at low energies(< 30 keV). In most radiological examinations it does not play a
major role because the voltage used is typically in the range from 50 to 125 kV. For
mammography, however, the voltage is lower (22–34 kV) and Rayleigh scatter cannot be
neglected.

2. Photoelectric effect or photoelectric absorption (PEA) is a form of interaction of X-ray or

gamma photon with the matter. A low energy photon interacts with the electron in the
atom and removes it from its shell. The probability of this effect is maximum when
 the energy of the incident photon is equal to or just greater than the binding energy of
the electron in its shell ('absorption edge') and

 the electron is tightly bound (as in K shell)

The electron that is removed is then called a photoelectron. The incident photon is completely
absorbed in the process. Hence it forms one of the reasons for attenuation of X-ray beam as it
passes through the matter. PEA is the dominant process for X-ray absorption up to energies
of about 100 𝐾𝑒𝑉. PEA is also dominant for atoms of high atomic numbers.

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3. A second possibility is that the photon transfers only part of its energy to eject an electron
with a certain kinetic energy. In that case, a photon of the remaining lower energy is
emitted and its direction deviates from the direction of the incoming photon. The electron
then escapes in another direction. This process is called Compton scattering.
Compton Scattering is important for low atomic number specimens. At energies of 100
𝑘𝑒𝑉 -10 𝑀𝑒𝑉 the absorption of radiation is mainly due to the Compton Effect. The
scattered X-ray energy is reduced, but the scattered X-ray may still have enough energy
to reach the detector. Compton scattered X-rays give a random background signal, and so
their contribution to the image should be minimized to improve the CNR

4. A third mechanism is pair production. If the energy of a photon is at least 1.02 MeV, the
photon can be transformed into an electron and a positron (electron–positron pair). A
positron is the antiparticle of an electron, with equal mass but opposite charge. Soon after
its formation, however, the positron will meet another electron, and they will annihilate
each other while creating two photons of energy 511 keV that fly off in opposite
directions. This process finds its application in nuclear medicine.

X ray detectors
To produce an image from the attenuated X-ray beam, the X-rays need to be captured and
converted to image information. Some detectors for digital radiography are relatively recent
developments. Older but still in use are the screen–film detector and the image intensifier.

Screen–Film detector
Photographic film is very inefficient for capturing X-rays. Only 2% of the incoming X-ray
photons contribute to the output image on a film. Therefore, an intensifying screen is used in
front of the film. These intensifying screens are composed of a scintillator, such as 𝐺𝑑2 𝑂2 𝑆
crystals, held together by a binder material. The scintillator in the intensifying screen
converts incident X-ray photons to visible light, which then expose the silver halide emulsion
on the film. It decreases the mAs required to produce a particular density and hence decreases
the patient dose significantly. In cassettes, which use double emulsion films, two screens are
used, mounted on both sides of the cassette.
The intensifying screen is composed of high Z compounds that have high absorption
efficiency for X-rays. Thicker intensifying screens absorb more X-ray photons than thinner

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screens, but the scintillation light that is emitted in a thicker screen diffuses greater distances
to reach and expose the film emulsion. This results in more light spread, which reduces the
spatial resolution of the screen.

Film

1. Film is composed of a thin plastic base coated on one or both sides with a layer of
light-sensitive emulsion consisting of silver halide (about 95% 𝐴𝑔𝐵r and 15% 𝐴𝑔𝐼).
2. Emulsion is very sensitive to both white light and X-rays. When exposed to light, the
silver halide grains absorb optical energy and undergo a complex physical change.
3. Each grain that absorbs a sufficient amount of photons contains dark, tiny patches of
metallic silver called development centers.
4. When the film is developed, the development centers precipitate the change of the
entire grain to metallic silver.
5. The more light reaching a given area of the film, the more grains are involved and the
darker the area after development. In this way a negative is formed. This is the final
output image.

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The Quality of the image contrast, resolution, and noise
Any medical imaging system must be judged on its ability to deliver diagnostically useful'
images. The value of the images depends on the contrast and resolution they display and on
the presence of interfering noise, distortion and artifacts.

Radiographic contrast refers to the extent to which various different tissue structures within
the body are displayed as different shades of gray in the image. Contrast is determined in part
by the inherent properties of the tissues, such as their thickness, density and chemical
composition.

Having point source and placing anti scatter grid between the patient and the image receptor
can effectively remove much scatter radiation and improve contrast.

The image resolution of a radiographic system depends on several factors.

1. The size of the focal spot. The anode tip should make a large angle with the electron
beam to produce a nicely focused X-ray beam.
2. The patient. Thicker patients cause more X-ray scattering, deteriorating the image
resolution. Patient scatter can be reduced by placing a collimator grid in front of the
screen. The grid allows only the photons with low incidence angle to reach the screen.
3. The light scattering properties of the fluorescent screen.
4. The film resolution, which is mainly determined by its grain size.

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Computed Tomography
Tomography refers to the cross-sectional imaging of an object from transmission data
collected by illuminating the object from many different directions. The impact of this
technique in diagnostic medicine has been revolutionary, since it has enabled doctors to view
internal organs with unprecedented precision and safety to the patient. Computed tomography
(CT) is the modernized tomography in which the computers are used for the numerical
reconstruction of the image itself out of un-image-like raw data. CT allows superb clarity and
tissue contrast by eliminating the confusion caused by the overlapping tissues in three
dimensions. CT scanners consist of an X-ray source that produces a fan-beam which
penetrates the patient and impinges on a bank of detectors. This complete assembly rotates
around a central core to produce a sequence of intensity measurements over 360° and yields a
two dimensional map of the linear attenuation coefficient throughout that slice.

CT scanners have been evolving continuously through various configurations of X-ray tube
and detectors. The current CT has fixed array of detectors and mechanically fixed but
electronically movable X-ray source; that is nothing physically moves.

Mapping of linear attenuation coefficient

Computed tomography involves irradiation of one transverse slice of tissue at a time, and
yields a two dimensional map of the linear attenuation coefficient throughout that slice.
The mapping process involves the mathematically partitioning the slice under examination
into a square matrix of thousands of small tissue volume elements called as voxels. The
matrix size is commonly expressed in terms of number (𝑀) of voxels in each dimension. A
square 256 × 256 matrix contains about 65𝑘 (65000) voxels. Voxels in CT are on the order

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of 1mm2 in cross sectional area in several millimeters in depth. The matrix size 𝑀 × 𝑀, the
size of the pixel (𝑏) and the linear dimension of the field of view (𝐹𝑂𝑉) are related as
𝑀. 𝑏 = 𝐹𝑂𝑉 (6)

The image reconstruction process involves determination of the linear attenuation coefficient
associated with every voxel. The computed map attenuation coefficient is eventually
displayed as a matrix of pixels of various shades of gray with one pixel normally
corresponding to each voxel.

CT Numbers (Hounsfield Numbers)

X-ray linear attenuation coefficient of each individual voxel is first calculated by the
reconstruction process and used to calculate the CT number values. The definition of CT
number is given as

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 𝜇 − 𝜇𝐻2 𝑂 (7)
CT number = × 1000
𝜇𝐻2 𝑂

where 𝜇𝐻2𝑂 is the linear attenuation coefficient of water at the effective energy of the beam
and 𝜇 is that of tissue in the voxel of interest. CT numbers with this normalization are
expressed in Hounsfield units (H).

Tissue Component CT Number (H)

Water 0
Air -1000
Dense bone +1000
Blood 42-58
Blood clot 74-81
Heart 24
Cerebrospinal fluid 0-22
Muscle 44-59
Normal liver 50-80
Fat -20 to -100
Lung -300

In a window, range of CT numbers is displayed with shades of gray, ranging from black to
white. Width control adjusts the range of CT numbers displayed with contrast. Also
reducing window width increases image contrast. CT has very high contrast sensitivity as a
window can be set to enhance very small tissue density differences. Window level describes
the center of the scale.

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Types of CT scanners
The first generation or Parallel beam Geometry

This is the simplest technically and the easiest with which to understand the important CT
principles. Multiple measurements of X-ray transmission are obtained using a single highly
collimated X-ray pencil beam and detector. The beam is translated in a linear motion across
the patient to obtain a projection profile. The source and detector are then rotated about the
patient isocenter by approximately 1 degree, and another projection profile is obtained. This
translate-rotate scanning motion is repeated until the source and detector have been rotated by
180 degrees. The highly collimated beam provides excellent rejection of radiation scattered in
the patient; however, the complex scanning motion results in long (approximately 5-min)
scan times.

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Second Generation: Fan beam, Multiple Detectors

Scan times were reduced to approximately 30 sec with the use of a fan beam of X-rays and a
linear detector array, so that only six rotational movements were required to obtain the data
for one slice. A translate-rotate scanning motion was still employed; however, a larger rotate
increment could be used, which resulted in shorter scan times. The reconstruction algorithms
are slightly more complicated than those for first-generation algorithms because they must
handle fan-beam projection data.

Third Generation: Fan beam, Rotating Detectors

A fan beam of X-rays is rotated 360 degrees around the isocenter. No translation motion is
used; however, the fan beam must be wide enough to completely contain the patient. A
curved detector array consisting of several hundred independent detectors is mechanically

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coupled to the X-ray source, and both rotate together. As a result, these rotate-only motions
acquire projection data for a single image in as little as 1 sec. Third-generation designs have
the advantage that thin tungsten septa can be placed between each detector in the array and
focused on the x-ray source to reject scattered radiation.

Fourth Generation: Fan beam, Fixed Detectors

In a fourth-generation scanner, the X-ray source and fan beam rotate about the isocenter,
while the detector array remains stationary. The detector array consists of 600 to 4800
(depending on the manufacturer) independent detectors in a circle that completely surrounds
the patient. Scan times are similar to those of third-generation scanners. The detectors are no
longer coupled to the X-ray source and hence cannot make use of focused septa to reject
scattered radiation. However, detectors are calibrated twice during each rotation of the X-ray
source, providing a self-calibrating system. Third-generation systems are calibrated only once
every few hours.

Spiral/Helical Scanning

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When the continuous motion of the X-ray tube is combined with a continuous advance of the
patient table along the axis of the scanner we have helical scanning. Typical table velocities
are 1 - 10 mm/s; a complete 360 degree rotation can be achieved in 0.5 s and the nominal fan
beam thickness is 1 mm or greater.
In the context of helical scanning a parameter called pitch is defined as the ratio of the
distance that the patient couch moves in one rotation to the slice thickness. In other words, for
a couch advance of 10 mm and a nominal slice width of 10 mm, the pitch is 1. Pitch values
are typically in the range of 1 to 2 depending on the required spatial resolution in the
direction of the couch motion.

CT Image quality

Image quality is determined by a combination of factors, including:

1. Development and design that has changed over the years
2. General performance and maintains of the equipment
3. How the equipment is operated.

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