M e d i c a l P hy s i c s a n d I n f o r m a t i c s R ev i ew

Shetty et al. Computed Radiography Image Artifacts Medical Physics and Informatics Review

Computed Radiography Image Artifacts Revisited

Chandrakant Manmath Shetty 1 Ashita Barthur Avinash Kambadakone Nilna Narayanan Rajagopal Kv
Shetty CM, Barthur A, Kambadakone A, Narayanan N, Kv R

OBJECTIVE. Computed radiography (CR) has provided a ready cost-effective transition from screen film to digital radiography and a convenient entrance to PACS. This article revisits artifacts encountered in CR systems. These artifacts may obscure abnormalities, mimic a clinical entity, or hamper image quality. CONCLUSION. With the new-generation CR systems, software- and hardware-related artifacts have decreased, making operator errors more evident. The purpose of this study is to establish the current trend of CR artifacts and the new facets in identifying and resolving problems quickly that will help prevent future occurrences. This article also brings to light the importance of constant review required of this extensively studied topic to avoid diagnostic misadventures. omputed radiography (CR) systems based on photostimulable phosphor (PSP) image detectors (i.e., imaging plates) were first introduced commercially in 1983 [1]. Such systems are widely accepted in radiology departments because they are cost-effective solutions to the shift from conventional filmbased imaging to digital imaging, whereby the existing radiography equipment can be retained and used. The transition to digital imaging is completed by installing CR readers and replacing film-based cassettes with image platebased CR cassettes. In our hospital, as in most major hospitals in India, the CR system is used for most of the hospitals general radiography work flow. Unlike the competing digital technology, CR is particularly suitable for bedside radiographic examinations, which usually are the worst images in general radiography because of the emergency conditions under which the examinations are performed. The wide latitude of CR improves the consistency of good-quality bedside radiographs. The image quality of CR on large body parts, such as the chest and abdomen, is better than that of digital radiography, whereas digital radiography is preferred for small body parts and extremities. Also, the CR system has the advantage of positioning flexibility for difficult views, because CR cassettes can be placed in any position, which is not possible in digital radiography sys-

Keywords: artifacts, computed radiography system DOI:10.2214/AJR.10.5563 Received August 13, 2010; accepted after revision September 14, 2010.
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tems [2]. Unlike digital radiography systems, a multiple cassette size option is available in CR systems. Even though digital radiography is gaining in popularity, CR will continue to play a significant role in an emergency setup. After performing cost analysis and capacity utilization of general radiography, CR still scores over digital radiography [3]. In todays era of CT and MRI, radiography still remains the primary imaging technique. Hence, it is imperative to improve the quality of radiographs by constant advancements in technology. However, even with technologic improvements in CR systems, we continue to encounter artifacts that degrade image quality, leading to misdiagnoses that may have medicolegal implications. In this article, we discuss and illustrate the various CR artifacts encountered in our clinical practice, along with their remedial measures. Workflow of CR Systems CR Readout Process Image acquisition is made using an imaging plate, which is a PSP-based plate made of barium fluorohalide (Figs. 1 and 2). One imaging plate is used for each exposure. The imaging plate is enclosed in a cassette, which is similar to a screen film cassette. The plate is now exposed to x-rays using standard radiographic equipment. During the exposure, electrons in the phosphor plate are excited to a higher energy state; these excited electrons

All authors: Kasturba Medical College Manipal, Madhavnagar, Manipal, Karnataka 576104, India. Address correspondence to C. M. Shetty (drcmshetty@yahoo.com).

WEB This is a Web exclusive article. AJR 2011; 196:W37W47 0361803X/11/1961W37 American Roentgen Ray Society

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Shetty et al. are trapped and form a latent image. This latent image is processed and retrieved by placing the imaging plate in a CR reader, which is also called a digitizer. Processing of Image The following steps are used to process the image (Fig. 2), First the cassette is opened in the CR reader with release of the imaging plate from the cassette. Second, the imaging plate is moved by the rollers for scanning by the laser beam. Third, the laser light stimulates the trapped electrons to become free and return to a lower energy state, which results in the release of light photons. The two lights (laser light and the released light photon) have different wavelengths, which forms the basis for image retrieval. This helps in identification of the light photons of higher energy and shorter wavelength by the photomultiplier tube (PMT), because the image signal is separate from the laser light, which is of a longer wavelength and lesser energy than the signal from the CR digitizer (or reader). Fourth, the light released from the imaging plate is collected by the fiber-optic light guide and strikes a PMT, where it produces an electronic signal. Fifth, the electronic signal is digitized and stored in a display monitor and later sent to a PACS. Sixth, the image plate is then exposed to a high-intensity halogen lamp, which erases any residual energy remaining from a prior exposure. Finally, the image plate is returned to the cassette, which is ready for reuse. Artifacts can be generated at each step of the CR image work flow. CR artifacts are broadly classified into image acquisition artifacts (Table 1) and image-processing artifacts (Table 2). Image Acquisition Artifacts: Operator Errors Image acquisition is performed by radiographers with the use of an imaging plate. As in film-based imaging, operator errors in CR systems contribute to image acquisition artifacts. Operator errors are all the more likely if the technique is new to the radiographer. The cassette with the imaging plate needs to be safely kept away from heat, humidity, and any source of radiation. If the department has multiple-vendor CR systems, CR cassette orientation is important, because cassette designs and constructions are different. Operator errors include twin artifacts, uncollimated images, delayed scanning, exposure through the back of the cassettes, inappropriate exposure factors, improper grid usage, scatter radiation, errors in cassette care and carelessness, and the light bulb effect. Twin Artifacts (Double Exposure) The exposure technique during radiography plays a very important role in preventing erroneous diagnosis. If the radiographer accidentally takes two subsequent exposures, one during inspiration and another during expiration, it will lead to duplication of images (Fig. 3). Double exposures can lead to errors in interpreting the position of line and catheters [4]. Such erroneous diagnoses resulting from improper exposure can have medicolegal implications. Double exposure is an operator error that accounts for 2% of all rejected images [5]. Proper knowledge of the usage of x-ray equipment is necessary to prevent such errors. Uncollimated Images Because the imaging plate is very sensitive to scatter radiation, primary beam collimation is very important not only to prevent radiation exposure but also to prevent unsharp images (Fig. 4). If the image collimation is not parallel to the imaging plate, proper borders will not be recognized, resulting in bizarre or nondiagnostic images [6]. Proper collimation should be done in accordance with the cassette size and the body part being imaged. Delayed Scanning The imaging plate contains PSP, which is sensitive to x-rays. The PSP changes to an intermediately unstable state after receiving energy in the form of x-rays. This state is not stable, and if the phosphor remains unstimulated, it returns to its normal state after a prolonged delay through spontaneous phosphorescence. Thus, a delay between acquisition and processing of the image will lead to fading of the image (Fig. 5). Twenty-five percent of the stored signals will be lost in about 10 minutes to 8 hours after exposure, and more slowly afterward [7]. One study concluded that statistically significant degradation of gray-level values and contrast occurs in plates scanned half an hour or longer after exposure [8]. In our experience, fading was evident after a delay of 2436 hours. The possible reason for this fading is that the central primary beam consists of high-energy photons, whereas the low-energy photons are in the periphery. Hence, the fading starts from the periphery, a point that distinguishes this kind of fading from that which occurs because of underexposure. To prevent this artifact, the delay between exposure and the readout process should be kept to minimum. This principle should be inculcated in radiographers by proper training and knowledge about CR technology in general and the imaging plate in particular. Exposure Through the Back of the Cassette Understanding of cassette orientation by radiographers is important. Cassettes are designed and constructed in different ways by different vendors, so any exposure through the back of the cassette will leave its own pattern of artifacts [9]. In our case (Fig. 6), the artifact could have been mistaken for a tracheostomy tube if we had failed to recognize its artifactual nature. Proper education of radiographers in handling of cassettes should be performed to prevent this type of artifact. Inappropriate Exposure Factors OverexposureA wide range of responses to various incident exposures is characteristic of CR systems, whereas film is optimally sensitive to a restricted range of exposures. This is because the acquisition and display events occur separately so that compensation for under- and overexposures is possible with the algorithms applied to the digital data. However, like any other electro-optical system, CR has a fixed dynamic range and, hence, a limit of adjustment [10]. Although CR is more tolerant of incorrect exposure factor selection, it cannot compensate for extra noise, loss in subject contrast, and a signal out of its range of adjustment. Overexposure of the imaging plate leads to irreversible darkening of the image, obscuring minute details (Fig. 7A). UnderexposureIn cases of marked underexposure (Fig. 7B), the image will appear grainy owing to quantum mottle. Such images can be identified by looking at a high sensitivity number in the parameter display area, and these images must be read with caution, because subtle findings may be masked by the reduced signal-to-noise ratio [11]. Proper exposure factors should be used according to the body part and patients build, to prevent poor image quality. Radiographers should be conversant about the dynamic range and limitations of CR systems. Improper Grid Usage: Moir Pattern Selection of grid frequency is important, because grids with low grid line rates are known to cause a moir pattern, resulting in suboptimal image quality [9]. The moir pattern is

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Computed Radiography Image Artifacts seen in images caused by using a grid with a frequency of 33 lines/cm, which are oriented with grid lines parallel to the plate readers scan lines (Fig. 8). Grids with 60 lines/cm or more should be used, and the grid lines should also run perpendicular to the plate readers laser scan lines [9]. Scatter Radiation The imaging plate is highly sensitive to scattered radiation (Fig. 9). Therefore, cassettes should be kept away from radiation fields, because radiation leads to a deterioration of image quality. No object should be kept on a cassette when it is in a radiation field, because the object will be imprinted on the image, leading to unwarranted repeating of the radiograph. Hence, the cassette must be protected from all sources of ionizing radiation, including scatter radiation, as well as heat and humidity [9]. A cassette seen to be lying unidentified in the radiography room should be erased before use. If the cassette was previously exposed or kept in a field of radiation, it has to be put through the process of erasure before reuse because it will hamper the quality of the image and cause erroneous artifacts. TABLE 1: Image Acquisition Artifacts
Artifact Twin artifacts Uncollimated images Delayed scanning Causes Two subsequent exposures on same imaging plate or double exposure Improper collimation Delay between acquisition and processing of image Appearance Duplication of images Unsharp images Fading of image Remedy Proper knowledge of usage of x-ray equipment Proper collimation in accordance with cassette size and body part Proper knowledge of radiographers to check that no delay occurs between acquisition and processing

Care and Carelessness CR cassettes with imaging plates must be stored and handled carefully. Negligence with imaging plates is one of the primary causes of artifacts. Buckling occurs as a result of mishandling of imaging plates by radiographers during the cleaning process, which causes kink marks (Fig. 10). Such marks tend to occur at the sites where the imaging plate is bent and can imitate pathologic conditions. To prevent this artifact, cassettes and image plates should be handled with care. Light Bulb Effect Artifactual darkening of the lower and outer portions of an image relative to the remainder of the image is caused by backscattered radiation entering the PSP imaging plate from the patients bed (Fig. 11). The source of this artifact can be attributed to an increased exposure for obese patients or uncollimated x-ray beam. This increased exposure is due to the wide dynamic range and high sensitivity of the imaging plate. When it occurs in a chest radiograph, this artifact can be misread as a pneumothorax or pneumoperitoneum in a supine patient. It can also alter the contrast and brightness of the affect-

ed portions of the image, potentially making abnormalities unclear [11, 12]. Reducing backscatter by lowering the kilovoltage or by more precise collimation will limit the prevalence and impact of this artifact. Image-Processing Artifacts Image-processing artifacts can arise from the imaging plate, the rollers in the CR reader that carry the imaging plate, and the plate reader, in which a laser is used to scan the imaging plate. The light photons thus emitted are collected by the plate reader or light guide and are converted into electrical signals, amplified, digitized, and used to form the image. Image-processing artifacts are further subclassified into hardware- and software-induced artifacts. Hardware-Induced Artifacts CR cassettes use storage PSP imaging plates instead of conventional films and intensifying screens. Imaging plates use the principle of phosphorescence. As the name suggests, they do not emit light immediately after x-ray exposure; instead, they store x-ray energy in the form of a latent image. The latent image is later read in the CR machine

Exposure through back of cassette Inappropriate exposure factors Overexposure Underexposure Improper grid usage

Poor basic knowledge of construction of Various patterns of shading according Proper education of radiographers in handling cassettes to cassette design of cassettes Improper exposure settings Improper exposure settings Darkening of image Proper exposure factors to be used based on body part and patient build

Grainy image owing to quantum mottle Knowledge of dynamic range and its limitations in computed radiography system Usage of grids with 60 lines/cm or more; grid lines should run perpendicular to plate readers laser scan lines Protect cassette from any unwanted radiation and erase cassettes before using Cassettes and image plates should be handled with care Reduce back scatter by lowering the peak kilovoltage or by more precise collimation

Usage of grids with low grid frequencies Different types of moir pattern

Scatter radiation

Cassette placed in vicinity of scattered radiation Mishandling of imaging plate during cleaning process Back-scattered radiation entering imaging plate from patients bed due to increased exposure for obese patients or due to uncollimated x-ray

Deterioration of quality of image and imprints of objects placed over cassette Kink marks Darkening of lower and outer portions of an image relative to remainder of image

Care and carelessness Light bulb effect

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Shetty et al. using a laser. Hardware-induced artifacts can be due to the imaging plate, rollers, plate reader, and cassette. Imaging plate artifactsImaging plate artifacts can be attributed to cracks resulting from aging of the imaging plate and rollerinduced artifacts. As the imaging plate passes through the plate reader, the imaging plate bends over the rollers. Over a period of time, the plates show signs of mechanical stress in the form of cracks. These cracks usually first become visible on the edges of the imaging plate, where they do not hinder image interpretation for diagnostic purposes. As the deterioration progresses, cracks appear closer to the central imaging plate area (Fig. 12). If screens are not cleaned on a regular basis, bent, or handled without cotton gloves, the aging process is hastened [6]. Artifacts due to cracks can be prevented by changing imaging plates. A properly maintained imaging plate can last for 5 years, after which the imaging plate needs to be changed. TABLE 2: Image-Processing Artifacts
Artifact Hardware-induced artifacts Imaging plate Artifacts due to cracks on imaging plate Artifacts due to dust particles on imaging plate Roller artifacts Disparity artifact Damage of imaging plate due to rollers Dust over rollers Malfunctioning rollers Plate reader artifact Cassette-related artifact Software-induced artifacts Image transmission errors Communication error artifact Data cable malfunctioning artifact Power failure during image transmission Missing lines or pixels in resulting image Failure of data cables in the power unit Alternating radiopaque and of digitizer or computed radiography radiolucent lines reader Wrong body part selection or malfunctioning halogen bulbs Radiograph should be repeated Replace data cables Malfunctioning of rollers in digitizer Defective scanning resulting in alteration in image contrast Periodic cleaning of rollers in computed radiography reader Warrants immediate cleaning of rollers Maintenance and cleaning of rubber rollers by company service personnel twice yearly Periodic cleaning and recalibration of feed rollers Periodic cleaning of light guide by service personnel Replacement of cassette Damaged imaging plates during frequent transportation Dust particles wedged over imaging plate Cracks Focal radiopacities Change imaging plate Regular cleaning of imaging plates with ethyl alcohol Causes Appearance Remedy

In some cases, artifacts are the result of dust particles on the imaging plate. The image in Figure 13 shows focal radiopacities overlying the soft tissues that are due to dust over the imaging plates, which mimics calcification or foreign bodies embedded in the soft tissue. Regular cleaning of imaging plates is the key to a good radiograph. Some manufacturers recommend the use of ethyl alcohol for cleaning imaging plates. Paper towels or gauze should not be used because they leave fibers on the plate; instead, the use of lint-free cloth is advisable. After cleaning, leave the plate to dry for approximately 10 minutes. Once weekly cleaning is advisable. Roller artifactsRollers are used within the CR reader to transport the imaging plate for scanning of latent images by the laser and subsequent erasure by the high-intensity halogen lamp. During this process, the imaging plate is constantly in contact with the rollers, which transport the imaging plate within and outside the CR reader.

Disparity artifacts are due to malfunctioning of rollers in the digitizer, which causes defective scanning. The defective scanning alters the image contrast in the upper and lower half of the image, because the laser beam power determines the fraction of the stored energy released, which in turn is influenced by the scan time. Higher laser power can release more of the trapped electrons, but this happens at the cost of loss of spatial resolution as a result of increased depth of the laser beam and increased spread of the stimulator light in the phosphor layer [7]. Thus, in the example shown in Figure 14, the lower half of the image was exposed to the laser beam for a longer time, resulting in a brighter image output that rendered the image suboptimal. This artifact can be prevented by periodic cleaning of the rollers in the CR reader machine. Imaging plates can be damaged by the rollers as well. Focal radiopacities, which appear as dots, are caused by mechanical damage of the imaging plate during its transport through

Mechanical damaging of imaging plate Focal linear radioopacities during transport through rollers Dust deposited over imaging plate during transport through rollers Slipping of feed rollers from transport assembly Multiple localized radiopacities Half-read image

Dirt over light guide or beam deflector Linear radiopaque line Cracked or weakened lead coating on back of cassette Linear radiolucent lines

Artifact due to improper erasure setting

Residual image is left in imaging Proper selection of body part for appropriate plate radiograph or halogen vapor bulbs must be changed

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Computed Radiography Image Artifacts the rollers. In the chest radiograph shown in Figure 15, linear radiopacities are seen in the right hemithorax, over the soft tissues and in the lung field; unless one is careful, one can easily misdiagnose the opacities as calcified granulomas in the lung. This artifact warrants immediate cleaning of the rollers. Dust on the rubber rollers is another source of artifacts. The radiograph of the pelvis in Figure 16A shows linear radiopaque lines that can be traced outside the pelvic region. These lines are due to dust on the rollers, which is deposited over the imaging plate during its transport through the rollers. The multiple localized radiopacities seen overlying the soft tissues of the left upper abdomen in the chest radiograph in Figure 16B could probably be the result of soft-tissue calcification. However, these opacities actually were caused by dirt over a localized area on the rubber rollers. To prevent this type of artifact, maintenance and cleaning of the rubber rollers by the manufacturers service personnel are required once every 6 months. Artifacts can be caused by slipping of the feed rollers, resulting in images being half read. For the same reason, in the example in Figure 17, the anterior half of a lateral skull radiograph is not seen. The linear radiopaque line over the lateral skull radiograph, found incidentally, is a plate reader artifact caused by dirt in the light guide. Periodic cleaning and recalibration of the feed rollers is of immense importance to prevent slippage of the feed rollers. The light collection guide also needs to be cleaned, but only by authorized service personnel of the manufacturer. Plate reader artifactThe light guide collects light emitted from the beam deflector when it is scanned by the laser, which then strikes the imaging plate. This information in the form of photons is taken up by the PMT for further amplification and image readout. Dirt over the light guide is seen as a linear radiodense line over the skull lateral radiograph (Fig. 17). Similar lines are also seen in Figure 18, which is a lateral radiograph of the knee joint, where linear radiopaque lines are noted overlying the femoral condyles. The light guide inside the scan unit should be cleaned by the manufacturers service personnel. Cassette-related artifactsThe back of the cassette consists of lead foil, which prevents scattered radiation. Scatter radiation through the back of the cassette produces black lines. These lines are analogous to the place where the lead coating was cracked or weakened [9]. These lines can mimic fractures unless they are traced beyond the margins of the involved bone. Figure 19 shows a lead foil artifact mimicking a hairline fracture of the head of first metacarpal bone. This type of artifact can be remedied by changing the cassette. Software-Induced Artifacts Software artifacts can be due to image transmission errors and improper erasure settings. Image transmission errorsArtifacts associated with image transmission errors can be caused by either communication errors or data cable malfunctioning. With a communication error artifact, the image, after digitization, gets electronically transferred to the display station computer. If there is a power failure during this image transmission, the resulting image may get corrupted and cannot be further edited. This artifact is seen as missing pixels [5] (Fig. 20). A repeat radiograph must be obtained. With a data cable malfunctioning artifact, the data cables take control signals to various modules of the CR reader, such as the laser gun, galvanometer jitter (beam deflector), and PMT, and are also responsible for the power supply to the laser gun and PMTs. Failure of transmission through these cables to different modules can cause an artifact (Fig. 21). The solution is to recheck and replace the data cables. Improper erasure settingThe erasure settings for different body parts are differently calibrated. Before inserting the cassette into the digitizer, the body part should be selected properly, because this setting determines the right erasure cycle time for the body part. If either the body part is erroneously selected or the power of the erasure halogen lamp is weakened, a residual image is left on the imaging plate (Fig. 22). This is confirmed by another exposure on the same imaging plate, where an image resulting from the previous exposure overlaps the new image. Proper selection of the body part for the appropriate radiograph should be done, and the halogen vapor lamps must be changed if they are weak. In conclusion, it is necessary to identify and pinpoint the source and type of CR artifacts because they can cause diagnostic errors with medicolegal implications. The people behind the machine are important, because most artifacts are due to operator error. Hence, it is necessary to have a practical guideline to monitor the quality control program. This goal can be accomplished by inspection of CR cassettes and imaging plates, quality control of equipment, and continual training of radiographers and radiologists to use this technology effectively to produce diagnostic-quality images. References
1. Chotas HG, Ravin C. Digital radiography with photostimulable storage phosphors: control of detector latitude in chest imaging. Invest Radiol 1992; 27:822828 2. Smith R. DR and CR, today and tomorrow. Imaging Econ 2004; December. Available at www. imagingeconomics.com/issues/articles/2004-12_05. asp 3. Reiner BI, Salkever D, Seigel EL, Hooper FJ, Siddiqui KM, Musk A. Multi-institutional analysis of computed and direct radiography. Part II. Economic analysis. Radiology 2005; 236:420426 4. Volpe JP, Storto ML, Andriole KP, Gamsu G. Artifacts in chest radiographs with a third-generation computed radiography system. AJR 1996; 166: 653657 5. Willis C, Thompson SK, Shepard J. Artifacts and misadventures in digital radiography. Appl Radiol 2004; January 1: 1120. Available at faculty. weber.edu/dnewham/Rad%20Tech%203463/ Supplemental%20Readings/Artifacts%20 and%20Misadventures%20in%20Digital%20 Radiography.pdf 6. Oestmann JW, Prokop M, Schaefer CM, Galanski M. Hardware and software artifacts in storage phosphor radiography. RadioGraphics 1991; 11: 795805 7. Seibert JA, Bogucki T, Ciona T. Acceptance testing and quality control of photostimulable phosphor imaging systems. Report of task group 10. Version 3.1. College Park, MD: American Association of Physicists in Medicine, 1997 8. Akdeniz BG, Grondahl HG. Effect of delayed scanning on storage phosphor plates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99:603607 9. Cesar LJ, Schueler BA, Zink FE, Daly TR, Taubel JP, Jorgenson LL. Artifacts found in computed radiography. Br J Radiol 2001; 74:195202 10. Willis CE. 10 Fallacies about CR. Imaging Econ 2002; December. Available at www. imagingeconomics.com/issues/articles/2002-12_02. asp 11. Solomon SL, Jost RG, Glazer HS, Sagel SS, Anderson DJ, Molina PL. Artifacts in computed radiography. AJR 1991; 157:181185 12. Tan LTH, Ong KL. Artifacts in computed radiography. Hong Kong J Emerg Med 2000; 7:2732. Available at www.hkcem.com/html/publications/ Journal/2000-2/p27-32.pdf

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Fig. 1Flowchart shows workflow of computed radiography system.

Light diverging lens Laser source

Galvojeter/ beam splitter

Photomultiplier tube Amplified electrical signal

A/D Imaging plate

digitization

Plate readout direction Plate movement direction Driving rollers

10110101

Digital data output

Fig. 2Flowchart shows computed radiography readout process.

Fig. 3Twin artifacts. A, Postprocedure radiograph of kidney and upper bladder of patient with ureteric calculus for whom double-J stent was placed on left side shows two double-J stents (arrows) resulting from double exposure, one during inspiration and other during expiration. B, Repeat radiograph taken to reconfirm shows single double-J stent (arrows).

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Fig. 4Uncollimated image resulting from lack of primary beam collimation. A, Radiograph of pelvis shows increased density over midportion and to right side of pelvis because of improper collimation. B, Subsequent pelvic radiograph with proper collimation shows uniform density over pelvis.

Fig. 5Delayed scanning. A and B, Radiographs of neck (A) and abdomen (B). Radiographs were subject to delayed readout (after 48 h). Both radiographs show decreased density in periphery as compared with center of images, as fading of image starts from periphery (arrows).

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Fig. 7Inappropriate exposure factors. A, Radiograph of hands shows darkening of image that obscures image details. Artifact is result of overexposure. B, Image shows underexposed grainy radiograph of kidney and upper bladder in which quantum mottle is evident and image quality is degraded. C, Control radiograph of same patient as in B using proper exposure factors.

Fig. 6Exposure through back of cassette. Radiograph of neck shows rounded radiopaque ring shadow (arrow) on right lower part of neck, which if overlooked, can be wrongly diagnosed as tracheostomy tube.

Fig. 8Improper grid usage leading to moir pattern. Radiograph of pelvis shows wavy radiolucent lines, resulting in suboptimal image, that were caused by usage of grid with frequency of 33 lines/cm.

Fig. 9Scatter radiation. Cassette was kept accidentally in radiography room with pen over it for some time. Radiograph of abdomen shows fading of image with image of pen overlying lumbar spine.

Fig. 10Kink artifact due to buckling of imaging plate. Excretory urography radiograph shows curvilinear marks (arrows) adjacent to right upper and lower pole calyces, which can mimic pyelosinus contrast extravasations. Other kink marks are seen in course of left ureter, which can be mistaken for calculi.

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A
Fig. 11Light bulb effect. A and B, Radiographs of chest (A) and abdomen (B) show darkening (arrows) in lower and outer portions of radiograph, obscuring details of image. Darkening occurs because of either high peak kilovoltage technique used in obese patients or improper collimation.

Fig. 12Artifacts due to cracks on imaging plate. Chest radiograph shows curvilinear opacity overlying left clavicle (arrow), which suggests cracks due to mechanical stress. Opacity can be misdiagnosed as parasitic calcification.

Fig. 13Artifacts due to dust particles on imaging plate. A and B, Radiographs of right elbow joint (A) and left thigh (B) show radiopacities (arrows) overlying soft tissues, which mimic soft-tissue calcification or foreign bodies but are actually due to dust over imaging plate.

Fig. 14Disparity artifact. This artifact occurs because of malfunction of roller in computed radiography reader, causing defective scanning and resulting in alteration in image contrast (arrows) in upper and lower half of chest radiograph. Lower half of chest radiograph was exposed to laser beam for longer time, which resulted in brighter image output that rendered image suboptimal.

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Fig. 15Damage of imaging plate due to rollers. Chest radiograph shows linear radiopacities (arrows) along right lateral chest wall. One can easily misdiagnose opacities as calcified granulomas in lung.

Fig. 16Dust over rollers. A, Radiograph of pelvis shows horizontal radiopaque lines (arrows) that can be traced outside margins of pelvis. B, Chest radiograph shows multiple scattered radiopacities (white arrows) overlying soft tissues of left upper abdomen due to dirt over localized area on rollers. These can be misdiagnosed as soft-tissue calcification. There is another radiopacity (black arrow) overlying right hypochondrium mimicking gallbladder calculus, which is actually caused by roller damage to image plate.

Fig. 17Malfunctioning rollers. Anterior half of lateral skull radiograph is not visualized because slipping of feed rollers, resulting image being half read (black arrow). Radiopaque line (white arrow) is plate reader artifact resulting from dirt in light guide.

Fig. 18Plate reader artifact. Lateral radiograph of knee joint shows horizontal thin radiopaque line (arrows) overlying supracondylar region. Artifact is attributed to dirt on light guide in plate reader.

Fig. 19Cassette-related artifact. Vertical linear radiolucent line (white arrows) seen over head of first metacarpal simulates linear fracture (black arrow) unless traced beyond margins of bone. Artifact is caused by cracks in lead foil in back of cassette.

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Fig. 20Communication error artifact. Lower part of radiograph (arrows) of knee joint was not visualized because of missing lines or pixels. Transmission of image was truncated because of sudden power failure.

Fig. 21Data cable malfunctioning artifact. Lateral view radiograph of lumbar spine shows alternating radipaque and radiolucent lines obscuring image details. Problem was narrowed down to malfunctioning data cables in computed radiography reader.

Fig. 22Artifact due to improper erasure setting. Radiograph of kidney and upper bladder shows superimposed residual chest radiograph image, which is seen in form of ribs and clavicle shadows (black arrows). Artifact was due to inadequate erasure setting for chest radiograph. Also note two side markers (white arrows).

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