2016

Measuring the Accuracy

Fluoroscopic Dose Area
Product
MINNESOTA STATE UNIVERSITY MOORHEAD, DEPARTMENT OF
PHYSICS AND ASTRONOMY, MOORHEAD MN
DANA J. KOCZUR
NOVEMBER 22, 2016

1|

Dana J.

Koczur

Abstract:
Dose Area Product (DAP) is an important value in fluoroscopy to monitor the dose a patient receives
during surgeries and use of the equipment. Potential sources of error were examined on a GE Elite 9900
C-arm fluoroscopy unit to determine how the radiation dose would be inaccurate and why. A Radcal DAP
Check Plus Analyzer was used as a comparison for a collimated beam of 100 cm2 in a 50-120 kVp range.
A percent difference between the two measurements could be explained by the increasing effects of
Compton scatter at higher energies. The average difference in DAP between the two measurement
techniques is 1.4% which is well within an acceptable range.

Introduction:
Medical imaging using radiation has played
a major role in clinical diagnosis and treatment,
allowing doctors to examine specific sections of
the human body without resorting to invasive
surgical
procedures [1].
X-ray
based
examinations are crucial in preventive medicine
and correct diagnosis [2]. Fluoroscopy is a type
of medical imaging producing a continuous xray video of 20-25 frames a second by using a
constant flow of radiation. This allows for a
better view of the motions of internal organs and
structures in the body. Fluoroscopy is used in
many procedures and examinations such as
angiograms, orthopedic surgery, and placement
of devices in the body [4]. Recording the dose
the patient is receiving is important during
procedures for patient safety and qualityassurance purposes.
The concern in fluoroscopy is monitoring an
accurate dose for patients. Dose reduction is
always a goal in medical imaging and having
accurate sensors will assist in this task. One way
to record the dose is using the dose area product
(DAP).
The goal of this experiment is to measure
the accuracy of fluoroscopic DAP by comparing
the value generated by the machines internal
DAP sensor and the DAP value measured by the
external DAP Radcal sensor.

Background:

Figure 1. This figure shows the production of X-rays in

an x-ray tube. An electron beam is accelerated between a
negative voltage and positive voltage at a spinning
tungsten anode where they lose energy and produce xrays.

Fluoroscopy uses a conventional x-ray tube

as seen in Figure 1. This x-ray tube consists of a
tungsten filament which is heated and releases
electrons. The electrons are accelerated across a
high voltage in the filament and drawn towards
the positive voltage in the anode. This stream of
electrons is the tube current (mA) and can be
changed with differences in the anode and
cathode voltage (kVp). The electrons are
directed to hit the rotating tungsten anode at a
small area referred to as the focal spot. X-rays
are generated from interactions between the
accelerated electrons and the electrons of the
tungsten anode. Two types of x-rays are
produced including characteristic radiation and
bremsstrahlung radiation [5]. The x-rays are
produced in many directions. Collimators form a

2|
beam from the x-rays orientated in the direction
of the tube window [2].
Characteristic x-ray production occurs when
a high energy electron collides with an inner
shell electron and both are ejected from the
tungsten atom [7]. This ejection leaves an open
space for an outer shell electron to fill with the
loss of energy emitted in the form of a photon.
The amount of energy it takes for an electron to
jump from one shell to another is characteristic
for each element.
Bremsstrahlung x-ray production occurs
when an electron is accelerated. In this inelastic
interaction the electron is deflected or stopped
causing energy loss in the form of an emitted
photon [7].
An example of x-ray spectra can be seen in
Figure 2.

Figure 2. X-ray Emission Spectra for a 100 kVp

tungsten target x-ray tube operated at 50, 100, and 150
mA [8]. kVp and exposure time are the same for the
three spectra. Increase in mA will increase the peak.

The amplitude of the x-ray spectra emitted can

be modified by controlling the tube current,
milli-amperes (mA) as seen in figure 2. The tube
current and exposure time in seconds describes

Dana J.

Koczur

the total number of electrons bombarding the

target (mA*sec).
The emission spectrum of the beam is
affected by many factors including filtration,
tube voltage, peak tube voltage, current, and
exposure time. An increase in tube voltage will
increase the high-energy limit of the x-ray
spectrum [8].
The production of x-rays causes electrons to
gain kinetic energy, which is the product of their
charge and the potential difference. Electron
energy is measured using electron volts (eV),
where eV is the kinetic energy of an electron
that has accelerated through a potential
difference of 1 volt [7].
This energy can be changed with different
settings. The increase in milla-amperes,
increases the power applied to the filament
which in turn produces more electrons and more
x-rays. The peak kilovolts increase the potential
difference between the cathode and anode. This
increases the energy of each electron as it strikes
the anode. When the electron strikes the anode,
it transfers most of its energy to the atoms of the
anode by ionizations and excitations. The kinetic
energy is released as heat dissipated over the
anode [7].
The beam is manually collimated. Similar to
a camera, an aperture is used to control [3] the
size and shape of the x-ray beam. This allows
for a specific, controlled area to be produced on
the surface of DAP sensor. The collimator is
made from lead plates to allow x-rays to escape
only through the opening at one end in one
direction. X-rays scattering or heading the
wrong direction hit the lead where the energy is
absorbed and scattered.

3|

Dana J.

Koczur

X-ray tubes are powered by a constant

potential or single polarity where the electrons
will be drawn from a positive anode to a
negative filament. A full-wave rectifier converts
alternating current to direct current. This allows
the tube to produce x-rays without pauses
between waves as seen in Figure 3. The
rectifiers have the capability to produce high

Figure 4. Attenuation coefficients () vs energy [10].

This shows the different types of radiation happing in
various energy ranges. The blue shaded area is the
experimental range from 0.50 MeV to 1.20 MeV.
Figure 3. This figure shows the changes in polarity
made to alternating current to have a more efficient use
in the x-ray tube and a constant production of x-rays.
This shows the tube voltage, tube current, and the x-ray
production for full-wave rectification.

frequency waveforms allowing production of

thousands of x-ray pulses per second by using a
constant potential. This means the peak voltage
(kVp) is highest after the rectification and is
occurring twice as often. Benefits of full
rectification include the most efficient x-ray
produced per unit time or more useful photons
produced per exposure. This means fewer
irrelevent low energy photons and shorter
overall exposure times. Full rectification also
prevents the flow of electrons from the anode to
cathode which can destroy the filament.
Three primary types of radiation scatter
affect this experimental range: coherent
scattering, photoelectric effect, and Compton
scatter. Two types of scatter interactions which
happen in the experimental range between 50
kVp and 120 kVp have a significant effect on

the data as seen in figure 4 using attenuation

coefficients. Attenuation is the absorption and
scattering interactions happening between
photons and matter [9]. The attenuation
coefficient is defined as the portion of the beam
of x-rays absorbed or scattered per unit thickness
of the absorbing material. This describes the
probability of a photon being scattered or
absorbed from the nucleus or an electron of one
of these atoms [8].

Figure 5. This diagram shows a photon undergoing

coherent scatter. There is small energy loss and a slight
change in directions.

Coherent scatter, or classical scatter, is a

form of photon interaction where the energy of

4|

Dana J.

the x-ray photon is small in relation to the

ionization energy of the atom [3] [10] [11]. At
low energy, the photon doesnt have enough
energy to escape and dislodge an electron from
its bound state therefore energy cannot be
transferred between the two. The photon will
not affect the electron, but will change the
direction of travel as seen in Figure 5. The
photons are deflected with little to no loss of
energy. Usually the photon is scattered in
approximately the same direction as the incident
photon. This type of scatter is not significant to
the measurements in this experiment.

Koczur

where is the photoelectric mass attenuation

coefficient. This shows the interaction is more
important for heavy atoms like lead and low
energy photons [12]. The relationship reveals
when energy is decreasing the probability of
photoelectric absorption increases rapidly. As a
result, in detectors, the absorption emits a small
output pulse whose amplitude is proportional to
the energy deposited by the photoelectron. No
energy is lost and the energy from the effect is
proportional to the energy from the photon [10]
=

(2)

is the x-ray, is the x-ray energy, and is

the binding energy holding the electron to the
atom in the K shell. These do not produce very
distinct energy or change the results of the DAP
sensor in this experiment.
Figure 6. This is a diagram of photoelectric effect
where the photon kicks the electron out of the k shell
of an atom. The photon will be absorbed in a reaction
equivalent in energy.

Photon

Photoelectric effect, or photoelectric

absorption, is an interaction between a low
energy photon (x-ray) with matter [8]. This low
energy photon has the same or just enough
energy to interact with an electron in the atom
and break it free. The photon is completely
absorbed and the electron, which is now called a
photoelectron, scatters as seen in figure 6. The
probability of absorption depends on the photon
energy and the atomic number of the atom. The
probability is greater the more tightly bound the
electron. The most affected are the K shell
electrons where over 80% of photoelectric
absorption happens [8]. The probability is
approximately

4
3

(1)

Figure 7. Compton scatter diagram showing the

relationship of the incident photon an electron initially
at rest. The energy from the photon gives kinetic
energy to the electron.

Compton Scatter will occur the most in the

energy range because of the probability of the
interactions increasing with the energy [13].
This occurs when a photon interacts with an
outer orbital electron. The collision of a photon
( ) with an atomic electron in which an elastic
collision occurs is shown in Figure 7. The
collision results in an electron gaining energy
(possibly the ionization of the targeted atom).
This will also change the direction ( ) of the
photon with a lower frequency. This occurrence
is also called backscatter. Compton scatter
causes the most interactions between x-rays and

5|

Dana J.

matter in the experimental interval between 50

kVp and 120 kVp. Compton scatter helps
indicate why measurements are inconsistent
between the detector and machine.
Understanding the energy behind Compton
scatter is important because during Compton
interactions the x-rays have about the same
energy as the primary photon rays. This reaction
is an effect of the conservation of energy and
momentum between the incident ray and the
mass of an electron starting at rest. The relation
between the photons energy before the collision
compared to after collision is [7]
1

(1cos())
2

(3)

where mec2 is the rest mass energy of the

electron and is the angle through which the
photon is deflected. When there is a direct
collision = 180 (10), a maximum amount of
energy is transferred to the stationary electron
resulting in a reflection straight back to the
sensor. This results in backscatter producing
more detected radiation than actually produced
in the initial beam. An increase in Compton
scatter directly correlates with the increase in
energy. There are more collisions occurring
resulting in more backscatter. This follows an
understanding of maximum energy transfer or
backscatter at = 180. This starts with
equations resultant of classical kinetic energy
relationship of
=

(4)

or
=

(5)

We can find the maximum energy by

2 =

(2 )2
2

= 2

22

(11)

Koczur

The maximum amount of energy transferred to

the stationary electron is called the Compton
edge [1]. The intermediate steps for the
derivation of maximum energy for Compton
scatter can be found in the appendix B. This
causes the most difficulties when using a DAP
sensor or performing surgery on a patient
because the radiation cannot be effectively
blocked since it is indirectly scattered from the
patient and other objects in the beam. When
more photons are detected than expected, it can
result in dark streaks along the lines of greatest
attenuation in the produced image [14].
A technique called beam hardening can be
used to rid the beam of photons attenuated more
easily leaving the high energy photons [14].
The use of potentially dangerous amount of
radiation and energy on patients has led to strict
guidelines for monitoring patient dose [2]. One
way to monitor patient dose is through dose area
product (DAP). DAP is the measurement of
radiation dose to air, times the area of x-ray
field [8] [6]. DAP is defined as dose in the air in
a plane, integrated over area of interest. The
DAP is not affected by the distance from the xray tube as seen in figure 8. This is only true
when neglecting absorption and scattering of
radiation in air and even for x-ray housing near
the couch table. This value can be useful to
assist in recording how much radiation a patient
is exposed to during a procedure. ALARA (as
low as reasonably acceptable) precautions were
taken to monitor distance, time, and shielding.
Fluoroscopy machines are equipped with
ionization chambers mounted on the x-ray tube
to intercept the entire x-ray beam and integrate
the absorbed dose over the area. These sensors
need to monitor for accuracy and calibrated
accordingly. Dose is measured in the
international system unit of Gray (Gy) or
absorbed energy per unit mass of tissue [6]
1

(12)

6|

Dana J.

This can be done with solid state detectors and

cassettes or a DAP sensor. Solid state detectors
use a conducting material activating when
ionizing radiation transversus the material. The

Figure 8. DAP is the entrance surface dose (mGy)

multiplied by the area irradiated (cm2). DAP is
independent of the distance from the X-ray source.

charged carriers create a current telling how

much radiation is being transmitted or dose [1].
To get DAP
= 0

(13)

= ()

(14)

where

D0 is the normalized beam measured in

milliGray a milliamp second (mGy/mAs), A is
the cross-sectional area of the beam (cm2).

Koczur

This is done using lead aprons over the image

receptor and underneath Radcal sensor.

Figure 9. This diagram shows the setup for measuring

DAP using isocenter of C-arm as a reference point.
Lead aprons are used to harden the beam.

Safety precautions were taken in every

fluoroscopy room when radiation is in use. A
lead vest was worn to protect from the scattered
radiation in the experiment.
The c-arm was first rotated allowing the xray tube to be directly above the table with no
objects obstructing the beam except for the
Radcal. The Radcal DAP sensor as seen in
Figure 10, was placed at the isocenter in the
radiation beam under the collimator. The
isocenter [15] is the point in space where the

Methods:
The diagram for the experimental setup can
be seen in Figure 9. A GE Healthcare OEC
9900 Elite Fluoroscopy C-arm and DAPCKP
DAPcheck Plus DAP Analyzer or Radcal were
used to measure DAP. Beam hardening occurs
when lower energy photons are filtered out [14].

Figure 10. This figure is the DAPCKP DAPcheck Plus

DAP analyzer. The buttons on the front allow for easy
use and switching between settings.

central ray or radiation beam passes. The

fluoroscopy machine used in this experiment has

7|

Dana J.

an isocenter. This creates a standard measuring

distance that can be used on different machines
or the same machine for different data
collections.
The method of measuring DAP uses a
Radcal Patient Dose Calibrator (PDC). This
produced immediate DAP results without the
use of cassettes and scanners. The Radcal has to
intercept the entire beam for an accurate reading.
The Radcal was placed at the isocenter of the carm for scans. It was situated on Styrofoam
stands with a folded lead apron underneath to
prevent as much back scatter from the table as
possible.
Measuring the DAP from the isocenter
places the beam accurately inside the
dimensions of the Radcal chamber cover grid. A
sheet of photostimuable phosphor was used to
collimate the beam on the DAP sensor.
Photostimuable phosphor consists of film of
BaFBr with trace amounts of Eu2+ coated on a
flexible plastic or paper [16]. This illuminates
when placed under the x-ray beam allowing for
manual collimation to the 100 cm2 area.
The dependent variable in this experiment
was dose. Each fluoroscopy scan was taken for 1
mGy of radiation at each kVp. The independent
variable in this experiment is the change in
energy.
Results:

Figure 11. Linear relationship between measured

average mGy vs kVp for the Elite 9900 and Radcal.
The DAP increases faster in the Radcal than the
fluoroscopy DAP.

Koczur

Figure 11 shows the relationship between

the averaged energy for each different exposure.
This shows how the increase in energy effected
the Radcal DAP values differently than the DAP
value on the fluoroscopy machine.

Figure 12. Relationship between the fluoroscopy and

Radcal DAP percent difference. Reasons for the
relationship are expected to be dependent on
Compton scatter occurring at higher energy levels as
kVp is increased.

Figure 12 shows the relationship between

the increase in energy and percent difference
between the fluoroscopy machine and the
Radcal DAP sensor. The error was found by
taking the standard deviation of the four
measurements at each separate energy level. As
the energy increased the percent difference
between the Radcal and the fluoroscopy
machine percent difference narrows until the
Radcal DAP is greater than the fluoroscopy
DAP. As the energy increased the Radcal values
increased at a rate 30% faster than the
fluoroscopy machine. This is expected to be a
result from Compton scatter occurring when
more energy is produced at higher energy levels.
Scatter is a result of radiation interactions
occurring with electrons and bouncing back into
the sensor producing more radiation than is
actually hitting the sensor. This scatter will not
affect the sensor on the fluoroscopy machine
because of its shielding and collimators.
The average percent difference between the
Radcal sensor and the GE Elite 9900
fluoroscopy machine is 1.4%.

8|

Conclusion and Future Work

In conclusion, this experiment tests the
relationship between the fluoroscopy GE Elite
9900 DAP and Radcal DAP sensor at the
isocenter of the C-arm. The percent difference
should be constant between the fluoroscopy
machine and the DAP sensor but changes as the
kVp is increased. In particular the experiment
shows the difference of measurements at 8
different kVp. The average percent difference
between the Radcal sensor and the fluoroscopy
machine is 1.4%. The changes in the percent
difference are expected to be from Compton
scatter effecting the DAP sensor. This accuracy
is well within industry standards of 30%. To
reduce the scatter lead is used between the
sensor and table but scatter is still effecting the
increase in DAP of the DAPCheck sensor.
This experiment has a vast amount of
variables and physics involved in a seemingly
simple reading of dose per area. This value,
dependent on the control of energy, scattered
radiation, and shielding, is important and
valuable quality control for monitoring changes
in equipment and procedures; procedures
affecting the lives of millions of people using
fluoroscopy equipment daily.
This was a great experiment to understand
the effects of DAP and energy in fluoroscopy
equipment. If I were given more time I could
continue my research designing and building
anti-scatter equipment and then experimentally
verifying the designs are reducing the Compton
scatter effecting the Radcal sensor and retesting
the accuracy. This experiment is only one small
scale test of these dynamics. The more scans
recorded at different energies will produce a
better linear result of percent difference between
the Radcal and fluoroscopy machine. Other

Dana J.

Koczur

sources of error in the experiment is scatter

radiation affecting the quality of the data
recorded on the Radcal DAP sensor.
Acknowledgements:
I would like to thank Steve Lindaas for his
advising and guidance during the project. I
would also like to thank William Duppler and
Kyle McCallum for assisting in equipment use at
Sanford and expertise in the field of medical
physics.

1|

Dana J.

Koczur

Appendix A: Recorded Data

Figure 13. DAP data collected from the GE Elite 9900 and Radcal for values between 50 kVp and 80 kVp. The percent
difference was taken for every set of values. The averages of the percent difference were used to plot the linear relationship
between DAP and the increase in kVp as seen in figure 9. The milliamps (mA) was kept the same through the entire
experiment.

Appendix B: Compton Scatter Derivation

(4)

or
=

(5)

and the energy conservation which gives

= +

(7)

where p, pe, and p, are the incident-photon,

scattered-electron,
and
scattered-photon
momenta, respectively. Using the relationship
between energy and momentum for a photon (3),
equation 6 and 7 become,

(6)

where is the photons energy after it is

scattered. Momentum conservation gives

= 2

(8)

assuming the electrons kinetic energy, T, is

related to its momentum by the classical
relationship then 7 becomes,
2 2 = ( )2 = (2 )2
We can find the maximum energy by

(9)

2|

Dana J.

2 =

(2 )2
2

22
2 + 2

Measure of Doses, Vasc. Interv. Radiol.

14, 711 (2003).

(10)

The maximum amount of energy transferred to

the stationary electron is called the Compton
edge [1]. These cause the most difficulties when
using a DAP sensor or when performing surgery
on a patient because of the energy produced and
the direction it travels.

[5]

J. H. Hubbell, Review of Photon

Interaction Cross Section Data in the
Medical and Biological Context, Phys.
Med. Biol. 44, R1 (1999).

[6]

K. Chida, H. Saito, H. Otani, M.

Kohzuki, S. Takahashi, S. Yamada, K.
Shirato, and M. Zuguchi, Am. J.
Roentgenol. Relationship between
Fluoroscopic Time, Dose-area Product,
Body Weight, and Maximum Radiation
Skin Dose in Cardiac Interventional
Procedures, (2006).

[7]

O. Daniel, G. Ogbanje, and P. S. A.

Jonah, X-ray and Scattering from Filters
Used in Diagnostic Radiology, Int. J. Sci.
Res. Publ. 3, 1 (2013).

[8]

W. R. Hendee, E. R. Ritenour, and K. R.

Hoffmann, Medical Imaging Physics,
Fourth Edition (2003).

[9]

C. A. Carlsson and G. A. Carlsson, Basic

Physics of X-ray Imaging, Linkoping
Univ. 3 (1996).

Appendix C: Settings for DAP on DAPCKP

DAPcheck Plus DAP analyzer
DAP is selected on the options on the
side of the Radcal. The Radcal was armed by
pressing CTL-Shift-R. The Radcal is ready when
the light by Measurement turns green.
Following an exposure, the Record screen
displays the desired DAP and was recorded for
each exposure.

Koczur

References:
[1]

M. Leiserson, The Future of Medical

Imaging, Aust. Hosp. Healthc. Bull. 139,
3, (2010).

[10]

R. S. Peterson, Experimental Ray

Spectroscopy and Investigations of
Environmental Radioactivity, 80 (1996).

[2]

D. Comaniciu, K. Engel, B. Georgescu,

and T. Mansi, Shaping the Future
Through Innovations: From Medical
Imaging to Precision Medicine, Med.
Image Anal. 33, 19 (2016).

[11]

F. Van Der Veen and F. Pfeiffer, J. Phys.

Condens. Coherent X-ray Scattering,
Matter 16, 5003 (2004).

[12]

A. C. Thompson, D. T. Attwood, E. M.
Gullikson, M. R. Howells, J. B.
Kortright, A. L. Robinson, J. H.
Underwood, K.-J. Kim, J. Kirz, I.
Lindau, P. Pianetta, H. Winick, G. P.
Williams, and J. H., X-ray Data Booklet,
Scofield, Berkeley Natl. Lab 8, 1125
(2001).

[13]

E. Aguirre, M. David, C. E. deAlmeida,

and M. A. Bernal, Impact of Photon
Cross Section Uncertainties on Monte
Carlo-Determined Depth-Dose
Distributions, Phys. Medica 1 (2016).

[3]

N. Serman, Production of X-rays and

Interactions of X-rays with Matter,
Columbia Univarsity (2002).

[4]

D. L. Miller, S. Balter, P. E. Cole, H. T.

Lu, B. A. Schueler, M. Geisinger, A.
Berenstein, R. Albert, J. D. Georgia, P.
T. Noonan, J. F. Cardella, J. St George,
E. J. Russell, T. W. Malisch, R. L.
Vogelzang, G. L. Miller, and J.
Anderson, J., Radiation Doses in
Interventional Radiaology Procedures:
The RAD-IR Study: Part I: Overal

3|

Dana J.

[14]

F. E. Boas and D. Fleischmann, CT

Artifacts: Causes and Reduction
Techniques, Imaging Med. 4, 229 (2012).

[15]

L. Ritschl, J. Kuntz, C. Fleischmann, and

M. Kachelrie, The Rotate-Plus-Shift CarmTrajectroy, Part I. Comptete Data
Med. Phys. 43, 2295 (2016).

[16]

K. Haris, P. J. Singh, A. Shastri, K.

Koczur

Sunanda, K. Babita, S. V. N. B. Rao, S.

Ahmad, and A. Tauheed,
Photostimulated Phosphor Based IMage
Plate Detection System for HRVUV
Beamline at Indus-1 Synchrotron
Radiation Source, Nucl. Instruments
Methods Phys. Res. Sect. A Accel.
Spectrometers, Detect. Assoc. Equip.
767, 199 (2014).