It’s amazing how quickly medical science made radiography one of its main diagnostic tools. Medicine had barely emerged from its Dark Age of bloodletting and the four humours when X-rays were discovered, and the realization that the internal structure of our bodies could cast shadows of this mysterious “X-Light” opened up diagnostic possibilities that went far beyond the educated guesswork and exploratory surgery doctors had relied on for centuries.
The problem is, X-rays are one of those things that you can’t see, feel, or smell, at least mostly; X-rays cause visible artifacts in some people’s eyes, and the pencil-thin beam of a CT scanner can create a distinct smell of ozone when it passes through the nasal cavity — ask me how I know. But to be diagnostically useful, the varying intensities created by X-rays passing through living tissue need to be translated into an image. We’ve already looked at how X-rays are produced, so now it’s time to take a look at how X-rays are detected and turned into medical miracles.
Taking Pictures
For over a century, photographic film was the dominant way to detect medical X-rays. In fact, years before Wilhelm Conrad Röntgen’s first systematic study of X-rays in 1895, fogged photographic plates during experiments with a Crooke’s tube were among the first indications of their existence. But it wasn’t until Röntgen convinced his wife to hold her hand between one of his tubes and a photographic plate to create the first intentional medical X-ray that the full potential of radiography could be realized.
One ill-advised spin-off of medical fluoroscopy was the shoe-fitting fluoroscopes that started popping up in shoe stores in the 1920s. Customers would stick their feet inside the machine and peer at a fluorescent screen to see how well their new shoes fit. It was probably not terribly dangerous for the once-a-year shoe shopper, but pity the shoe salesman who had to peer directly into a poorly regulated X-ray beam eight hours a day to show every Little Johnny’s mother how well his new Buster Browns fit.
As technology improved, image intensifiers replaced direct screens in fluoroscopy suites. Image intensifiers were vacuum tubes with a large input window coated with a fluorescent material such as zinc-cadmium sulfide or sodium-cesium iodide. The phosphors convert X-rays passing through the patient to visible light photons, which are immediately converted to photoelectrons by a photocathode made of cesium and antimony. The electrons are focused by coils and accelerated across the image intensifier tube by a high-voltage field on a cylindrical anode. The electrons pass through the anode and strike a phosphor-covered output screen, which is much smaller in diameter than the input screen. Incident X-ray photons are greatly amplified by the image intensifier, making a brighter image with a lower dose of radiation.
Originally, the radiologist viewed the output screen using a microscope, which at least put a little more hardware between his or her eyeball and the X-ray source. Later, mirrors and lenses were added to project the image onto a screen, moving the doctor’s head out of the direct line of fire. Later still, analog TV cameras were added to the optical path so the images could be displayed on high-resolution CRT monitors in the fluoroscopy suite. Eventually, digital cameras and advanced digital signal processing were introduced, greatly streamlining the workflow for the radiologist and technologists alike.
Get To The Point
So far, all the detection methods we’ve discussed fall under the general category of planar detectors, in that they capture an entire 2D shadow of the X-ray beam after having passed through the patient. While that’s certainly useful, there are cases where the dose from a single, well-defined volume of tissue is needed. This is where point detectors come into play.
In medical X-ray equipment, point detectors often rely on some of the same gas-discharge technology that DIYers use to build radiation detectors at home. Geiger tubes and ionization chambers measure the current created when X-rays ionize a low-pressure gas inside an electric field. Geiger tubes generally use a much higher voltage than ionization chambers, and tend to be used more for radiological safety, especially in nuclear medicine applications, where radioisotopes are used to diagnose and treat diseases. Ionization chambers, on the other hand, were often used as a sort of autoexposure control for conventional radiography. Tubes were placed behind the film cassette holders in the exam tables of X-ray suites and wired into the control panels of the X-ray generators. When enough radiation had passed through the patient, the film, and the cassette into the ion chamber to yield a correct exposure, the generator would shut off the X-ray beam.
Another kind of point detector for X-rays and other kinds of radiation is the scintillation counter. These use a crystal, often cesium iodide or sodium iodide doped with thallium, that releases a few visible light photons when it absorbs ionizing radiation. The faint pulse of light is greatly amplified by one or more photomultiplier tubes, creating a pulse of current proportional to the amount of radiation. Nuclear medicine studies use a device called a gamma camera, which has a hexagonal array of PM tubes positioned behind a single large crystal. A patient is injected with a radioisotope such as the gamma-emitting technetium-99, which accumulates mainly in the bones. Gamma rays emitted are collected by the gamma camera, which derives positional information from the differing times of arrival and relative intensity of the light pulse at the PM tubes, slowly building a ghostly skeletal map of the patient by measuring where the 99Tc accumulated.
Going Digital
Despite dominating the industry for so long, the days of traditional film-based radiography were clearly numbered once solid-state image sensors began appearing in the 1980s. While it was reliable and gave excellent results, film development required a lot of infrastructure and expense, and resulted in bulky films that required a lot of space to store. The savings from doing away with all the trappings of film-based radiography, including the darkrooms, automatic film processors, chemicals, silver recycling, and often hundreds of expensive film cassettes, is largely what drove the move to digital radiography.
After briefly flirting with phosphor plate radiography, where a sensitized phosphor-coated plate was exposed to X-rays and then “developed” by a special scanner before being recharged for the next use, radiology departments embraced solid-state sensors and fully digital image capture and storage. Solid-state sensors come in two flavors: indirect and direct. Indirect sensor systems use a large matrix of photodiodes on amorphous silicon to measure the light given off by a scintillation layer directly above it. It’s basically the same thing as a film cassette with intensifying screens, but without the film.
Direct sensors, on the other hand, don’t rely on converting the X-ray into light. Rather, a large flat selenium photoconductor is used; X-rays absorbed by the selenium cause electron-hole pairs to form, which migrate to a matrix of fine electrodes on the underside of the sensor. The current across each pixel is proportional to the amount measured to the amount of radiation received, and can be read pixel-by-pixel to build up a digital image.