Muhamad Fadlilah Bin Mukhlas D20091035126

Medical imaging is the technique and process used to create images of the human body (or parts and function thereof) for clinical purposes (medical procedures seeking to reveal, diagnose or examine disease) or medical science (including the study of normal anatomy and physiology). Although imaging of removed organs and tissues can be performed for medical reasons, such procedures are not usually referred to as medical imaging, but rather are a part of pathology.

 Radiology began as a medical sub-specialty in first decade of the 1900's after the discovery of x-rays by Professor Roentgen. The development of radiology grew at a good pace until World War II. Extensive use of x-ray imaging during the second world war, and the advent of the digital computer and new imaging modalities like ultrasound and magnetic resonance imaging have combined to create an explosion of diagnostic imaging techniques in the past 25 years. Over the past 100 years, the technological advances of x-ray tubes, power generation, imaging detectors, imaging techniques, nuclear medicine, magnetic resonance, and ultrasound have been astounding

 Film Cassettes For the first fifty years of radiology, the primary examination involved creating an image by focusing x-rays through the body part of interest and directly onto a single piece of film inside a special cassette. In the earliest days, a head x-ray could require up to 11 minutes of exposure time. Now, modern x-rays images are made in milliseconds and the x-ray dose currently used is as little as 2% of what was used for that 11 minute head exam 100 years ago. Further, modern x-ray techniques (both anal of film screen systems and digital systems, described below) have significantly more spatial resolution and contrast detail. This improved image quality allows the diagnosis of smaller pathology that could not be detected with older technology.

 Fluorescent Screens The next development involved the use fluorescent screens and special glasses so the doctor could see xray images in real time. This caused the doctor to stare directly into the x-ray beam, creating unwanted exposure to radiation. In 1946, George Sc hoenander developed the film cassette changer which allowed a series of cassettes to be exposed at a movie frame rate of 1.5 cassettes per second. By 1953, this technique had been improved to allow frame rates up to 6 frames per second by using a special "cut film changer."

 Contrast Medium A major development along the way was the application of pharmaceutical contrast medium to help visualize organs and blood vessels with more clarity and image contrast. These contrast media agents (liquids also referred to as "dye") were first administered orally or via vascular injection between 1906 and 1912 and allowed doctors to see the blood vessels, digestive and gastro-intestinal systems, bile ducts and gall bladder for the first time.

 Image Intensifier In 1955, the x-ray image intensifier (also called I.I.) was developed.it is an imaging component which converts xrays into a visible image (real time image). By the 1960's, the fluorescent system (which had become quite complex with mirror optic systems to minimize patient and radiologist dose) was largely replaced by the image intensifier/TV combination. Together with the cut-film changer, the image Intensifier opened the way for a new radiologic sub-specialty know as angiography to blossom and allowed the routine imaging of blood vessels and the heart.

 Nuclear Medicine Nuclear Medicine studies (also called radionuclide scanning) were first done in the 1950s using special gamma cameras.Nuclear medicine studies require the introduction of very low-level radioactive chemicals into the body. These radionuclides are taken up by the organs in the body and then emit faint radiation signals which are measured or detected by the gamma camera. Positron Emission Tomography or PET It is a nuclear medicine scan that uses cross sectional data and reconstructs it as an image, much like CT scanning, but can see specific problems better such as brain tumors, and the heart and lungs. The most recent innovation in PET has lung cancer patients inhaling a radionuclide or low level radioactive chemical rather than an oral or intravenous contrast medium. There is also SPECT which is similar to PET that uses a gamma camera, but is not as sensitive. PET cameras are much more expensive than SPECT cameras and are only in the largest medical centers.

 Single-photon emission computed tomography (SPECT) a 3D tomographic technique that uses gamma camera data from many projections and can be reconstructed in different planes. A dual detector head gamma camera combined with a CT scanner, which provides localization of functional SPECT data, is termed a SPECT/CT camera, and has shown utility in advancing the field of molecular imaging. In most other medical imaging modalities, energy is passed through the body and the reaction or result is read by detectors. In SPECT imaging, the patient is injected with a radioisotope , most commonly Thallium 201TI, Technetium 99mTC, Iodine 123I, and Gallium 67Ga

 Ultrasound Scanning In the 1960's the principals of sonar (developed extensively during the second world war) were applied to diagnostic imaging. The process involves placing a small device called a transducer, against the skin of the patient near the region of interest, for example, the kidneys. This transducer produces a stream of inaudible, high frequency sound waves which penetrate into the body and bounce off the organs inside. The transducer detects sound waves as they bounce off or echo back from the internal structures and contours of the organs. These waves are received by the ultrasound machine and turned into live pictures with the use of computers and reconstruction software.

Ultrasound representation of Urinary bladder (black butterfly-like shape) and hyperplastic prostate

 Digital Imaging Techniques Digital imaging techniques were implemented in the 1970's with the first clinical use and acceptance of the Computed Tomography or CT scanner, invented by Godfrey Hounsfield. Analog to digital converters and computers were also adapted to conventional fluoroscopic image intensifier/TV systems in the 70's as well. Angiographic procedures for looking at the blood vessels in the brain, kidneys, arms and legs, and the blood vessels of the heart all have benefited tremendously from the adaptation of digital technology.

 Benefits of digital technology to all x-ray systems: less x-ray dose can often be used to achieve the same high quality picture as with film digital x-ray images can be enhanced and manipulated with computers digital images can be sent via network to other workstations and computer monitors so that many people can share the information and assist in the diagnosis digital images can be archived onto compact optical disk or digital tape drives saving tremendously on storage space and manpower needed for a traditional x-ray film library digital images can be retrieved from an archive at any point in the future for reference.

 Computed Tomography (CT) CT imaging (also called CAT scanning for Computed Axial Tomography) was invented in 1972 by Godfrey Hounsfield in England. Hounsfield used gamma rays (and later x-rays) and a detector mounted on a special rotating frame together with a digital computer to create detailed cross sectional images of objects. Hounsfield's original CT scan took hours to acquire a single slice of image data and more than 24 hours to reconstruct this data into a single image. Today's state-of-the-art CT systems can acquire a single image in less than a second and reconstruct the image instantly. The invention of CT was made possible by the digital computer. The basic algorithms involved in CT image reconstruction are based on theories proposed by the scientist Radon in the late 1700's. To honor his remarkable discovery, Hounsfield was awarded the Nobel Prize and was granted Knighthood by the Royal Family of England.

An original head-only CT scanner from 1974

A CT scan image showing a ruptured abdominal aortic aneurysm

 Magnetic Resonance (MR) MR principals were initially investigated in the 1950s showing that different materials resonated at different magnetic field strengths. Magnetic Resonance (MR) Imaging (also know as MRI) was initially researched in the early 1970s and the first MR im aging prototypes were tested on clinical patients in 1980. MR imaging was cleared for commercial,clinical availability by the Food and Drug Administration (FDA) in 1984 and its use throughout the U.S. has spread rapidly since. Countless scientists have been involved in the innovation of magnetic resonance.The development of MR imaging is attributed to Paul Lauterbur and scientists at Thorn-EMI Laboratories, England, and Nottingham University, England.

 In nuclear medicine imaging the use of multi-detector systems for total-body, brain and heart scanning have recently gained increasing popularity. There is a strong development of the imaging systems with a large number of tiny crystals made by the newly developed high dense and fast responding materials.

 single large scintillation crystal with a large number of photo multiplier tubes (PMT): In the first method the gamma ray strikes a large circular or rectangle thin crystal and the induced scintillation light is distributed between the PMTs (Fig. 1A) according to their viewing spatial angles. The x and y positions of PMTs are weighted by their electric signal responses from all PMTs and the X and Y coordinates of the scintillation cloud striking the array of PMT and the corresponding energy is computed (Anger type of gamma camera). The intrinsic spatial resolution of the imaging device strongly depends on the crystal thickness, slightly less on the size / number / shape of PMT and the position circuit. The sensitivity of the system oppositely to the spatial resolution increases by the crystal thickness. The energy and time resolution depend mainly on the crystal material. Nowadays nearly all planar gamma cameras are of this kind.

 Large number of tiny scintillation crystals with position sensitive photo-multiplier tube (PSPMT): In the second method (Fig. 1B) the gamma ray is absorbed in a tiny crystal and all the induced scintillation light is collected by a small area of position sensitive photo multiplier tube which converts the incident light in a very thin layer into a charge or current which is then converted to digital E (energy) signal.(electron to electric signal) Each small sensitive area of PSPMT provides also corresponding spatial coordinates X and Y for the particular exposed crystal. The spatial resolution strongly depends on the size of the crystals and on the thickness and material of the septa. Each crystal represents a pixel in the final digital image. Thinner and longer the crystal and thinner the septa

 If gamma ray strikes the crystal too close to the reflector cover or to the optical fiber (crystal is inside optical fiber) then some of the ionization doesnt contribute to the scintillation light and therefore the energy signal is smaller. Because of this, a definite volume close to the edge, is not useful and is treated as scattered. For approximately 20 % of absorbed gamma rays, the reduction of the scintillation light will be present. Some of the signals coming from these 20 % will still be included in the lower part of the photo peak but some will be lost. The conclusion is that there is no meaning of using thinner sized crystals than 1-2 mm depending on the material (for NaI crystal this size is limited to 2 mm and for BGO crystal 1 mm). The sensitivity increases by the crystal length, density and cross sectional size. The energy resolution is improved by more efficient PSPMT and more effective collecting of scintillation light in crystal.

 Large semiconductor crystal with array of tiny n-p sensitive areas: In the third method (Fig. 1C) the incident gamma ray is absorbed in the region of p-n junction region of the semiconductor crystal and a large number of electron-hole pairs are created. Their number (approximately 3 - 5 eV/electron-hole pair is spent on average) is proportional to the energy of the gamma ray and is nearly ten times greater than the quantity of the scintillation light (approximately 30 eV per ionization). For the same factor the energy resolution is better. The efficiency of the late developed (cadmium zinc Telluride) CZT crystal is even better than for NaI. The intrinsic spatial resolution of the CZT gamma camera is considerably better and is about 2 - 3 mm for 140 keV compared to 3 - 4 mm for NaI gamma camera. On the other hand the collection time for electron-hole pairs is at least 100 times shorter than is the decay time for scintillation light in NaI crystal and therefore the increased count rate can be achieved (250.000 counts/s). The weight of such imaging system is 100 times lower and the CZT gamma camera is easily portable to emergency departments or elsewhere. It is expected that the price for such gamma camera will also be much lower because of the less complicated production.

Picture 1. Comparison between CZT camera and NaI Anger camera breast scans.

 Radiation damages the cell by damaging DNA molecules directly through ionizing effects on DNA molecules or indirectly through free radical formation. Deterministic effects: such as cell killing, can be more immediate and have a threshold above which severity increases with radiation dose. However, the threshold is not necessarily the same in each individual or tissue. While healing may ensue, necrosis and fibrotic changes in internal organs, acute radiation sickness, cataracts, and sterility may also occur. For acute deterministic effects, large doses are usually required, Stochastic effects: such as mutations, can result in cancer and hereditary effects. Cancer induction can have a long latency period. Estimating cancer risks associated with diagnostic x-rays using epidemiological tools is difficult because of extrapolation to low radiation doses, recall bias, and different x-ray energies used at various institutions. Most lowdose human ionizing radiation risk estimates come from the atomic bomb survivors in Japan. Other sources of information include laboratory cellular mutation studies and studies on various strains of mice; of course, the applicability to humans remains to be seen.

 hereditary effects: Radiation damage to the gonads during the reproductive period of life produces mutations to the gametes. Inherited diseases can encompass a range of mild disorders to serious consequences, including death or severe mental defects. However, no human population studies have shown hereditary effects from typical background ionizing radiation doses.

 Physicians should limit ionizing radiation exams especially CT scans, which produce a massive radiation dose. Physicians must consider the consequences of ionizing radiation in ordering radiology exams This involves things like selecting the right protocols, being sure that the examination is the right examination at the right dose for the right patient, and keeping the dose as low as possible but adequate enough to get the results that are needed to make an accurate diagnosis Equipment needs to be regularly calibrated and all safety features must be in working order. more comparative effectiveness research needs to be done

 Patients Must Be Proactive About the Imaging Tests They Undergo Patients should monitor their own exposure to medical radiation and make their physician aware when a test is being ordered that they might have undergone the same test in the past Physicians should consider for patients who are referred for additional imaging whether there is an alternative imaging test that involves less radiation exposure than what is being ordered The amount of radiation you get is very much related to your body habitus; if you are thinner, you will get a lower dose of radiation

 An imaging-based trial will usually be made up of three components: A realistic imaging protocol. The protocol is an outline that standardizes (as far as practically possible) the way in which the images are acquired using the various modalities (PET, SPECT, CT, MRI). It covers the specifics in which images are to be stored, processed and evaluated. An imaging centre that is responsible for collecting the images, perform quality control and provide tools for data storage, distribution and analysis. It is important for images acquired at different time points are displayed in a standardised format to maintain the reliability of the evaluation. Certain specialised imaging contract research organizations provide to end medical imaging services, from protocol design and site management through to data quality assurance and image analysis. Clinical sites that recruit patients to generate the images to send back to the imaging centre.