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First, let’s see an example of an artifact:
index patient 1.
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Easy to tell – the opacity is
outside of the patient.
Wait, what is
this?
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The patient was sent to the fluoroscopy room
for evaluation and extraction of a possible
foreign body located in the soft tissue anterior
to the distal left tibia.
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Fluoroscopy
There’s no foreign
body. It was an
artifact.
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New x-ray
taken after the
fluoroscopy,
with a
different
x-ray cassette.
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New x-ray
taken after the
fluoroscopy,
with a
different
x-ray cassette.
There’s no foreign
body. It was an
artifact.
Wednesday, October 16, 2013
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Now let’s see another patient with a more
serious case.
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52 year-old woman who had just underwent a
pelvic surgery.
After the surgery, there was a needle missing
(incorret needle count).
An x-ray was performed to check whether the
needle had been forgotten inside the patient.
All information provided to the radiologist was:
“Pelvic surgery. Incorrect needle count.”
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PACS, MAH
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PACS, MAH
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The linear opacities in the previous slide do not
have exactly the density we would expect from
a metal object, but their shape and location
(specially the pelvic opacity) raise enough
suspicion.
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PACS, MAH
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The linear opacity between the 11th
and 10th rib has dissapeared. It was an
artifact.
PACS, MAH
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PACS, MAH
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The linear opacity at the pelvis is still there.
This greatly increases the likelihood of it
being an actual needle.
PACS, MAH
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Before telling you the end of this case, let’s talk
about the technology called “Computed
Radiography”.
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Mount Auburn Hospital – Cambridge, MA 22
COMPUTED DIGITAL
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COMPUTED DIGITAL
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Let’s learn how an image is obtained through
Computed Radiography.
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Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011. 27
The cassette is the box which contains an
imaging plate instead of a conventional film.
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After exposure to the x-rays, the operator
brings the cassette to the CR scanner
machine. Before doing that, it chooses the
proper settings in the CR scanner for each
image. Different body parts require different
scanning settings.
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The electric signals generated by the
photomultiplier tube are electronically
processed to a digital signal, which is then
sent to the PACS – picture archiving and
communications system.
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After the scanning is done, the CR scanner
exposes the imaging plate to the light of an
halogen lamp. This causes it to be erased.
Different types of x-rays require different
exposures to the halogen lamp to ensure the
image is completely erased. This is one of the
reasons why the operator must configure the CR
scanner according to what body part was x-rayed
before inserting the cassette.
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Finally, the imaging plate is inserted back into
the cassette and it CR scanner releases it for
reuse.
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Now let’s see some examples of artifacts in
Computed Radiography and how they can be
addressed.
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The imaging plate
Operator errors
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L J Cesar, B A Schueler, F E Zink et al. Artefacts found in computed radiography. The
British Journal of Radiology, 74 (2001), 195–202
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Dirt in the light guide
Remedy:
Professionally service
the CR reader.
Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
41
L J Cesar, B A Schueler, F E Zink et al. Artefacts found in computed radiography. The
British Journal of Radiology, 74 (2001), 195–202
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Exposure through the
back of the cassette
Remedy:
Ensure proper
education of the
radiographers.
Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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Delayed scanning
Fading of the periphery of the image
while the center seems adequately
exposed. Remedy:
Ensure plates are
scanned as soon as
possible after exposure.
In 8 hours, 25% of
signals stored in the
imaging plate are lost,
but this does not mean
that the image will be
25% less visible. In this
example, the cassette
was inserted in the CR
scanner 48 hours after
having been exposed to
the x-rays.
Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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The imaging plate is very sensible and will be affected by Scatter radiation
scattered radiation even if it is not directly under the source
of x-rays. This image was taken from a cassette that was
forgotten inside a room where x-rays were being Remedy:
performed. There was a pen over the cassette and its shape Erase the cassette and
protect it from
got imprinted on the imaging plate.
radiation.
Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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Double exposure
Remedy:
Proper knowledge on
the usage of x-ray
equipment.
Two double-J stents are seen in the
left kidney, because the imaging plate
was exposed two times -- one during
inspiration, another during expiration,
making the kidney be at different
heights at each exposure.
Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
51
L J Cesar, B A Schueler, F E Zink et al. Artefacts found in computed radiography. The
British Journal of Radiology, 74 (2001), 195–202
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Improper erasure
Remedy:
Clean the rollers and
replace the imaging
plate.
Damaged areas on the imaging plate
become opaque in the image. The
alignment of the linear opacities allow
you to identify the rollers as the cause
of that damage to the imaging plate.
Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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Dust on the rollers
Remedy:
Clean the rollers.
The scattered
opacities easily
mimick real findings
and can be difficult
to identify as
artifacts. The opacity
pointed by the black
arrow could be a
gallstone. A new x-
ray, with a different
cassete (and thus
different imaging
plate), should help
identify the findings
as artifacts.
Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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Dust over the imaging plate
Remedy:
Clean the imaging plate.
Remedy:
Use grids with no less than 60 lines
per cm, and positioned
perpendicular to the plate reader’s
scan lines.
Remedy:
Replace the cassette.
Remedy:
Select special processing settings
for images with wide dynamic
ranges.
Re-imaging might be necessary.
Remedy:
Professionally service the electronic
equipments.
Remedy:
Discard the imaging
plate.
Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
69
L J Cesar, B A Schueler, F E Zink et al. Artefacts found in computed radiography. The
British Journal of Radiology, 74 (2001), 195–202
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Damage to the
imaging plate
Remedy:
Replace the imaging
plate.
This time, the location of
the artifact incidentally
makes it easier to suspect it
is an artifact. However, a
new x-ray, with a different
cassette and thus a different
imaging plate, should be
ordered for proper
confirmation.
Remedy:
Replace the imaging
plate.
Can be misdiagnosed as a
calculus in the ureter.
A new radiograph, using a
different cassette and
thus a different imaging
plate, will help identify
the opacities as artifacts.
Physical buckles in the
imaging plate are
unrecoverable – the plate
will need to be discarded.
Shetty et al. Computed Radiography Image Artifacts Revisited. AJR:196, January 2011.
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Now let’s go back to our index case.
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“52 year old woman, pelvic surgery, incorrect
needle count.”
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PACS, MAH
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This is already the second x-ray and the
opacity is still there, in the same place.
PACS, MAH
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The attending radiologist then ordered a third
x-ray, but with the following requests:
1. Remove the cushioning from under the pelvis of
the patient.
2. Use a new cassette that wasn’t used before.
3. Do not use any grid to cover the cassette.
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PACS, MAH
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The linear opacity has disappeared from the
pelvis. It was an artifact. No re-operation is
needed.
PACS, MAH
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Fabrício Sampaio Péres Kury
Federal University of Rio de Janeiro Medical School
September 23rd 2013, Beth Israel Deaconess Medical Center
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1. Gillian Lieberman, M.D, from Harvard Medical School.
2. J. Pierre Sasson, M.D., Ralph L. Reichle, M.D., George L. Cushing, Jr.,
M.D., and the people at the Radiology department of Mount Auburn
Hospital.
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