Fluoroscopy & Interventional Imaging: Bushberg - Chapter 9 Rsna & Aapm Physics Curriculum: Module 13

FLUOROSCOPY & INTERVENTIONAL IMAGING
BUSHBERG CHAPTER 9
RSNA & AAPM PHYSICS CURRICULUM: MODULE 13
Rene (Dickinson) Butler, MS, DABR
Medical Physicist
University of Washington Medical Center
Department of Radiology
Diagnostic Physics Section
rdickins@uw.edu
General Fluoroscopy:
Modes of Operation & System Components
UW and Rene Butler, MS, DABR
Fluoroscopy vs Projection Radiography
PARAMETER G.I. FLUOROSCOPY RADIOGRAPHY
kVps 60 - 120 50 - 130
mA values
0 - 5 (continuous)
200 - 800
0 - 100 (pulsed)
X-ray Tube Focal Spot Size 0.3 - 0.6 mm 1.0 - 1.2 mm
Exposure Duration 0.5 - 15 minutes 0.01 - 0.3 seconds
Image Receptor Input Radiation Dose per image 0.01 - 0.15 mGy / image 4 - 10 mGy/image
Patient skin Dose Rates 10 - 60 mGy / min 0.2 - 10 mGy / image
Source-to- Skin Distance (SSD) 30 - 50 cm 60 - 145 cm
Source-to-Image Receptor Distance (SID) 80 - 120 cm 100 or 182 cm
Typical Spatial Resolution
1 - 2.0 LP/mm (Image Int.)
3 - 10 LP/mm
2.5 - 3.0 LP/mm(Flat Panel)
Image Quantum Mottle High Low
Staff Exposure to Scattered Radiation Yes No
c.f. AAPM/RSNA Web Module: Fluoroscopy systems. Section IV. Table1.
Low(er) Exposure Rates general fluoroscopy
Continuous typically display is 30 fps or greater
Maximum dose rate = 10 R per min [87.3 mGy/min] (10 CFR Part 20)
Pulsed fluoroscopy
Maximum dose rate = 10 R per min [87.3 mGy/min] (10 CFR Part 20)
High(er) Exposure Rates leads to rapid dose accumulation
High dose rate Specially activiated fluoroscopy (enable buttons or
separate pedal)
Maximum dose rate = 20 R/min [175 mGy/min] with audible signal (10 CFR Part 20)
Not found on modern fluoroscopy suite systems, common on c-arms
Road Mapping & Digital Subtraction Angiography (DSA): real-time
subtraction of pre- and post-contrast injection images to improve the
perception of low-contrast vessels
3D rotational angiography or CT acquisitions
Fluoroscopy
Modes of Operation
Typical entrance exposure rates to the patient:
For thin patients/body parts: dose rate is roughly 1-2 R per min [8.7 to
17 mGy per min] for thin body parts
Skin injury threshold in normal mode can be reached in
approximately 118 to 230 min
For average patient sizes: dose rate is roughly 3-5 R per min [26 to
44 mGy/min
For heavy patient sizes: dose rate is roughly 8-10 R per min [70 to
87.3 mGy/min
Fluoroscopy
Modes of Operation
If temporal resolution is not needed (e.g. guiding a catheter from the
femoral artery to aortic arch), use pulsed fluoro to reduce patient (and
personnel!) dose
Also reduces motion
30 fps
15 fps
display
display
c.f. AAPM/RSNA Physics Tutorials for Residents: MS Van Lysel. Fluoroscopy: Optical
Coupling and the Video System. Radiographics. Nov 2000; 20: 1769-1786.
Fluoroscopy
Modes of Operation
Continuous vs. pulsed
Continuous 30 fps w/ 33 msec per frame @ 2 mA (0.066 mAs)
Pulsed 30 fps w/ 10 msec per frame @ 6.6 mA (0.066 mAs)
** Same exposure to patient, but less motion artifact **
Pulsed 15 fps w 33 msec per frame @ 2 mA (0.033 mAs)
1 second exposure
Continuous Fluoro
30 fps, 33 msec
per frame
Pulsed Fluoro
15 fps, 33 msec
per frame
Pulsed Fluoro
30 fps, 10 msec
per frame
2 mA
6.6 mA
2 mA
Fluoroscopy
Modes of Operation
8.76 mGy per R
14.7 R per min = 128.8 mGy per min
Fluoroscopy
Modes of Operation
Digital Subtraction Angiography
(DSA): real-time subtraction of
pre- and post-contrast injection
images to improve the
perception of low-contrast
vessels
Removal of background anatomy
and tissue
Increased image noise
Clinically used for diagnostic and
therapeutic applications of vessel
visualization throughout the entire
body
c.f. AAPM/RSNA Physics Tutorial for Residents: Digital Fluoroscopy. Radiographics. Vol 21. March 2001.
DSA cerebral arteriogram. a. Unsubtracted digital fluoro.
b-d. Subtracted DSA images obtained at 3 progressive
time points during contrast injection.
Fluoroscopy
Imaging Techniques
Road mapping
A DSA sequence is performed and the frame w/ maximum vessel
opacification is identified
The road map mask is subtracted from subsequent live fluoro images to
produce real-time subtracted fluoro images
e.g.: a wire is steered by using the road map for cues on maneuvering through
vasculature
3D rotational angiography
Philips Xper CT
c.f. AAPM/RSNA Physics Tutorial for Residents: Digital Fluoroscopy. Radiographics. Vol 21. March 2001.
Fluoroscopy
Imaging Techniques
What type of configuration is preferred for a urology suite?
Why?
Kidneys & bladder are closer to the image receptor, therefore, reducing
focal spot blur.
What is the negative of this room set-up?
Because the tube is above the patient, the scatter radiation is projected
back into the procedure room; whereas for GI fluoroscopy rooms, the
entrance point is below the table and lead shield curtains attenuate the
scatter radiation.
Web Modules
Clinical Applications
Under table tube
Gastrointestinal room
Remote rooms
C-arm (mobile)
Operating rooms or floor clinics
Orthopedic joint replacement, endoscopy, colonoscopy
Positioning flexibility
Angiography, IR rooms
Over table tube
Urology
c.f. AAPM/RSNA Web Module: Fluoroscopy systems. Section III.A-E.
Web Modules
Clinical Applications
Fluoroscopy System Components
Image Intensifier (II) vs Flat-Panel Detectors (FPD)
Flat-panel
detector
c.f. Bushberg, et al. The Essential Physics of Medical Imaging, 2nd ed., p. 232.
Image intensifier system components:
II vacuum bottle (housing); input screen (x-ray
to e
-
); electronic lenses; output phosphor (e
-
s to
visible light)
Lenses and aperature
Optical coupling w/ accessory port
Viewing electronic output image video or more
commonly charged-coupled device (CCD)
detectors
c.f. Bushberg, et al. The Essential Physics of Medical Imaging, 2nd ed., p. 232, 239.
Image Intensifier (II) vs Flat-Panel Detectors (FPD)
Review Questions
For the image intensifier shown, match the following: (answers may
be used more than once)
A. Light photons.
B. X-ray photons.
C. Microwaves.
D. Electrons.
E. Infrared photons.
I represents
II represents
III represents
IV represents
V represents
B.
B.
A.
D.
A.
In vacuum electrons (e
-
s) are influence by environment
Input screen converts x-rays to e
-
s
1 mm aluminum window creates vacuum
Support layer
Input phosphor Cesium Iodine (CsI) crystal; Converts x-rays to light
Photocathode Layer of antimony and alkali metal; emits electrons when struck
by light; 10-20% conversion efficiency
Electronic lenses 25 kV 35 kV electric field between input and output
(electronic gain)
Image Intensifier (II)
Output phosphor converts e
-
s to visible light
Zinc cadmium sulfide (ZnCdS)
Anode thin coating of aluminum on the vacuum side of output phosphor
Each e
-
interacts in the phosphor creating ~1000 light photons
Some fraction of the output light emitted by ZnCdS phosphor is reflected at the
glass window; known as veiling glare, which reduces image contrast
Image Intensifier (II)
Solid-state devices
Thin, carbon fiber protects CsI phosphor and photodiode array
INDIRECT digital detector
Input phosphor CsI converts x-rays to light photons
X-rays interact in CsI and create ionizations; some deposited energy is
emitted as light
Photodiode array
An array of detector elements each
element is 200 microns (0.2 mm)
Absorbs light and converts energy into free
electron charge that is stored in each cell
of the array
Charge stored is proportional to the incident
light, which is proportional to the # incident
(absorbed) x-ray
c.f. Granfors & Albagli. Scintillator-based flat-panel x-ray imaging detectors. Journal of the Society for Information Display. June 2009.
Flat-Panel Detectors (FPD)
Patient & Personnel Safety in Fluoroscopy
Identify the technique factors and appropriate system
features to use to optimize image quality while minimizing
patient dose.
1. FPD (or II) close to patient
2. Grid in
3. Collimate!
4. Increase SSD (source-to-skin distance) to
decrease ESD (entrance skin dose)
*Note: geometry limitations with
shorter personnel
AAPM/RSNA Resident Physics Curriculum: Module 13: Fluoroscopy & Interventional Imaging
Clinical Application
Describe the geometric factors that affect operator dose
during an IR procedure.
1. Lead apron
2. Thyroid shield
3. Protective eyewear
4. Radiation badge
5. Adjust dose settings when possible (pulse) to
reduce scatter
6. Distance, when possible
7. Shielding, when possible
Describe the geometric factors that affect operator dose during an IR procedure
scatter geometry for the frontal and lateral tubes in a NIR suite.
c.f. ZH Anastasian et.al. Radiation Exposure of the Anesthesiologist in the
Neurointerventional Suite. Anesthesiology 2011; 114: 512-20.
General set-up for angio/IR suites:
Frontal tube: positioned w/ tube
below patient
Scatter to personnel minimized
by lead drapes
Lateral tube: positioned so radiologist
is on the same side as the FPD or II
Scatter is projected from the
skin back toward the x-ray tube
Higher scatter for personnel on
tube side of lateral tube. Use
moveable shields!
General set-up for angio/IR suites:
Frontal tube: positioned w/ tube
below patient
Scatter to personnel minimized
by lead drapes
Lateral tube: positioned so radiologist
is on the same side as the FPD or II
Scatter is projected from the
skin back toward the x-ray tube
Higher scatter for personnl on
tube side of lateral tube. Use
moveable shields!
c.f. ZH Anastasian et.al. Radiation Exposure of the Anesthesiologist in the
Neurointerventional Suite. Anesthesiology 2011; 114: 512-20.
Describe the geometric factors that affect operator dose during an IR procedure
scatter geometry for the frontal and lateral tubes in a NIR suite.
c.f. Bushberg, et al. The Essential Physics of Medical Imaging, 2
nd
ed., p791.
Bushberg Table 23-18. Nuclear Regulatory Commission (NRC) Regulatory Requirements:
Maximum Permissible Dose Equivalent Limits
a
Maximum Possible Annual Dose Limit
Limits mSv rem
Occupational Limits
Total effective dose equivalent (ED) 50 5
Total dose equivalent to any individual organ
(except lens of eye)
500 50
Dose equivalent to the lens of the eye 150 15
Dose equivalent to the skin or any extremity 500 50
Minor (< 18 years old) 10% of adult limit 10% of adult limit
Dose to an embryo/fetus
b
5 in 9 months 0.5 in 9 months
Non-occupational (Public) Limits
Individual members of the public 1.0 per yr 0.1 per yr
Unrestricted area 0.02 in any 1 hr
c
0.002 in any 1 hr
c
a
These limits are exclusive of natural background and any dose the individual has received for medical purposes; inclusive of internal committed dose
equivalent & external effective dose equivalent (i.e., total effective dose equivalent).
b
Applies only to conceptus of a worker who declares her pregnancy. If the limit exceeds 4.5 mSv (450 mrem) at declaration, conceptus dose for
remainder of gestation is not to exceed 0.5 mSv (50 mrem).
c
This means the dose to an area (irrespective of occupancy) shall not exceed 0.02 mSv (2 mrem) in any 1 hour. This is not a restriction of
instantaneous dose rate to 0.02 mSv per hour (2 mrem per hour).
Radiation Protection and Fluoroscopy/IR
Badging OUTSIDE the lead near the neck/collar
Generally, no double badging (except pregnant personnel)
Monitors total exposure, eye dose, extremity
Total annual limit for occupation radiation worker is 50 mSv/year
Total eye lens dose limit is 150 mSv (or 20 mSv; ICRP) per year
Lead aprons
Lead equivalent = 0.25 mm: absorbs > 90% of scatter
Lead equivalent = 0.35 - 0.50 mm: absorbs 95 - 99% of scatter (but
heavier, so is it feasible to wear??)
Use a lead thyroid shield at all times
Protective gloves of 0.5 mm lead of greater should be worn if
hands are going to be near but outside the primary beam To
protect hands during fluoroscopy, it is recommended:
Keep hands out of and away from the x-ray field when the beam is on
unless physician control of invasive devices is required for patient care
during fluoroscopy
Work on the exit-beam side of the patient whenever possible
Monitor hand dose
Leaded glasses:
Recommended that all full-time radiology interventionists and
anesthesiologists should wear leaded eye protection
Measured lens entrance dose is ~2.5 +/- 2.0 Sv (radiologist);
therefore ~30,000 procedures to reach current 150 mSv/year limit
(based on current NRC Dose Limits)
NEW!! The ICRP recently released a statement stating lower dose
thresholds for cataracts were appropriate.
The previous ICRP threshold (and current NCRP or US threshold) of 4
Gy (acute exposure) and 8 Gy (chronic exposure)
Reduced to 0.5 Gy for acute and chronic exposures, based on recent
studies of patients and occupational workers.
Note, even though the USA has yet to adopt this ICRP threshold, it is
anticipated change.
Because of this lower cataract threshold, the ICRP slashed the
occupational dose limit for the lens of the eye to 20 mSv in a year,
averaged over a defined period of five years.
The cumulative lens dose should not exceed 50 mSv in any single
year.
Fluoroscopy the Ten Commandments
1. As patient size increases
As image quality decreases, patient dose increases, personnel
dose increases
2. Exposure time
Total fluoro time directly affects patient dose, but also distributing
dose over the skin (can you rotate/move tube to a different
position??)
3. Use appropriate dose and dose-rate settings
Pulsed vs continuous
Standard FOV vs mag modes
4. X-ray tube position
Raise/lower patient away from x-ray tube to decrease ESD
Lateral and oblique tube positions general have higher ESDs
c.f. LK Wagner & BR Archer. Minimizing Risks from Fluoroscopic X
Rays: Bioeffects, Instrumentation, and Examination. 2004: 4
th
Edition. UW and Rene Butler, MS, DABR
c.f. LK Wagner & BR Archer. Minimizing Risks from Fluoroscopic X Rays:
Bioeffects, Instrumentation, and Examination. 2004: 4
th
Edition.
5. Proximity of II or FPD to Patient improves image quality and
decreases radiation dose
SID = 110 cm, varied SOD
6. Inverse Square Law
Reduce the dose through the use of distance if and when you can.
Given: Exposure rate at 2 ft is 90 mR/hr
9 ft
2
4 ft
2
1 ft
2
2 ft
4 ft
6 ft
Exposure Rate at 4 ft = (90 mR/hr)(2ft/4ft) = 22.5 mR/hr
2
Exposure Rate at 6 ft = (90 mR/hr)(2ft/6ft) = 10 mR/hr
2
1 ft
1 ft
2 ft
2 ft
3 ft
3 ft
2
2
1
1 2

D
D
E E
Magnification
Electronic mag generally higher doses when using mag modes (though
may not always be
Geometric mag increase distance between patient and II; typically
increases dose by the square of the magnification
Grid remove grid for thin patients or if the image contrast is not
affected by the scatter
Collimation!!
Personnel Safety use time, distance and shielding to your
advantage whenever possible; always wear lead aprons, use badges
to monitor individual dose
Skin Injury Case Reports & Radiation Dose
Skin Injuries Case Reports
This is a 49-yr old woman with 8-yr history of refractory supraventricular tachycardia. The patient was exposed to about
20 min of fluoroscopy with her elbow about 20-25 cm from the x-ray source. The circular port of the x-ray system
defined the sharply demarcated border of the injury.
Fig.8b show sharply demarcated erythema above right elbow at 3 weeks after RF cardiac cath ablation.
Fig. 8c shows tissue necrosis 5 months after procedure.
Fig. 8d shows injury with humerus visible about 6.5 months after procedure.
Fig. 8e shows the surgical flap about 10 months after fluoroscopy procedure.
Fig 8b
Fig 8c
Fig 8d
Fig 8e
ref: ICRP Publication 85, Case 1 (photographs courtesy of T. Shope).
(a) The patients back 68 weeks after multiple coronary angiography and angioplasty procedures.
(b) The injury approximately 1621 weeks after the procedures. A small, ulcerated area is present.
(c) The injury approximately 1821 months after the procedures. Tissue necrosis is evident.
(d) Close-up photograph of the lesion shown in (c).
Radiation injury in a 60-year-old woman subsequent to
successful neurointerventional procedure for the treatment
of acute stroke. Estimated fluoroscopy time was more than
70 minutes; 43 imaging series were performed during
course of the procedure. The head was not shaved. Note
focal epilation on scalp and skin injury on neck but not on
scalp. No dose estimates were available for this case.
ref: Balter et al. Radiology. Feb 2010. Vol 254:2
UW and Rene Dickinson, MS
FDA Advisory
In the late 1980-early 1990s, the US FDA documented
reports of at least 40 cases of radiation-induced burns to
patients from fluoroscopically guided procedures.
Fluoroscopic radiation is a carcinogen. While the risk of
cancer from fluoroscopy is usually very small, it is
essential that the radiation be properly controlled to
minimize this risk to patients, to operators and to
personnel.
On September 9
th
, 1994, the FDA issued an advisory for
facilities that use fluoroscopy for invasive procedures.
FDA Advisory
Recommendations
Appropriate credentials and training for physicians
performing fluoroscopy
Operators be trained and understand system operation,
and implications of radiation exposure for each mode of
operation
Physicians be educated in assessing risks and benefits
on a case-by-case basis for patients
Patients be counseled regarding the symptoms and
risks of large radiation exposures
Physicians justify and limit use of high dose rate modes
of operation
Washington State Law
WAC 246-225-020
Operators shall be adequately instructed in safe operating
procedures and shall be able to demonstrate competence
A medical x-ray machine operator shall be licensed,
certified or registered by the department as either:
a licensed health care practitioner
a certified diagnostic or therapeutic RT
a registered x-ray technician
Nurses or PAs need training if asked to operate x-ray
equipment
Physician is ultimately responsible for assuring that the x-
rays are safely and properly applied and that appropriate
radiation protection measures are followed
Image Quality (Dose) in Fluoroscopy
Review Questions
A 9-in. multi-mode image intensifier (II) is switched to the 6-in.
mode. As a result, the image will be ________ , and the
automatic brightness control system (ABC) will _________ the
exposure to the II and the patient.
A. magnified, decrease
B. magnified, increase
C. minified, increase
D. magnified, not change
E. minified, decrease
Small FS general fluoroscopy (minimize blurring)
Large FS digital spots only (tube loading)
In general, the spatial resolution of the I.I. alone is 3.5-6.0
LP/mm
Smaller structures are minified less (spread over a larger portion of
the output phosphor), this enlargement of the displayed image
improves the limiting resolution of the imaging system
The typical spatial resolution of most current FPD image
receptors is about 2.5 3.0 LP/mm for all FOVs.
Web Modules
Clinical Applications Spatial Resolution
With regard to a flat panel, what is binning?
What is the advantage?
What is the disadvantage?
Example:
8 x 8 matrix; 10 photons per pixel
4 x 4 matrix; 160 photons per pixel
10 10 10 10 10 10 10 10
10 10 10 10 10 10 10 10
10 10 10 10 10 10 10 10
10 10 10 10 10 10 10 10
10 10 10 10 10 10 10 10
10 10 10 10 10 10 10 10
10 10 10 10 10 10 10 10
10 10 10 10 10 10 10 10
160 160
160 160
Less Quantum Mottle, the patient radiation dose can be
significantly reduced while maintaining the same image noise.
However, binning does reduce the spatial resolution of the image.
Binning is especially useful for a large FOV where there would be
too many pixels in the image
= sqrt(10) = 3.2
SNR = N/ = sqrt(N) = 3.2
= sqrt(160) = 12.6
SNR = 12.6
Web Modules
Clinical Applications Spatial Resolution (and noise)
What percent of dose is a single fluoroscopy image relative
to a general radiography image?
About 1% (typically 450 to 1800 images per minute of fluoroscopy)
0.01-0.15 mGy per image (fluoro)
4-10 mGy per image (radiography)
Web Modules
Clinical Applications Radiation Dose
Spatial resolution
System detector limitations FOV, matrix, DELs, video capabilities,
binning
e.g.: FPD detector element sizes
GI studies @ 2.5-3 lp per mm
Using mag, the resolution improves to @ 3.5-6 lp per mm
Television systems limit resolution to about 1-2 lp per mm for GI systems and 2-4 lp per
mm for angio systems
Focal spot size and geometry keep patient adjacent to detector!! This
reduces focal spot blur
Motion, temporal factors affecting image blur
In general, pulsed fluoro reduces motion blur improve resolution
Fluoroscopy
Factors Affecting Image Quality
Contrast
Scattered x-rays (grid), veiling glare (II only)
kVp and filtration if the average (effective) energy of the x-rays is
increased, then contrast decreases
Collimation decreases scatter contribution
Radiation dose and noise increasing the mA, decreases the noise and
therefore improved contrast
Image processing smoothing algorithms and frame averaging reduces
image noise, which improves contrast; edge enhancement algorithms
increase image noise, therefore contrast degrades
Contrast media (iodine, barium, or air) enhances contrast of anatomical
structures
Fluoroscopy
Factors Affecting Image Quality
Image Quality: II vs FPD
IMAGE QUALITY II Systems FPD Systems
If FOV is reduced (mag mode) improved spatial resolution
Improves or stays the same (no
geometric minification for FPD)
Binning n/a
reduces spatial resolution,
improved SNR by decreasing
mottle
Focal spot size use small FS to decrease focal spot blur, except for digital spots
Limiting resolution
II resolution (3.5-6 LP/mm), but
system resolution is limited by
television system (1-4 LP/mm)
limited by DEL (2.5-3 LP/mm)
Dynamic range limited generally, no limitation
Contrast
increasing the kVp and/or filtration increases the average energy
of the x-rays and the number of Compton scatter events, therefore
image contrast is degraded
Collimation
limits number of scattered photons and extraneous irradiation of
tissue
c.f. AAPM/RSNA Web Module: Fluoroscopy systems. Section VIII: A-F.
Goal is to keep the # photons constant maintains SNR regardless of
patient thickness (or attenuation)
c.f. AAPM/RSNA Web Module: Fluoroscopy systems. Section X.A-7.
Programming the generator:
If generator responds by
increase kV for thicker (more
attenuating) regions, then
contrast is compromised but
dose is lower
For procedures where contrast
is critical (e.g. angiography) the
generator programmed to
increase mA first. Preserves
contrast, but at the cost of
increased dose to patient
Fluoroscopy
Factors affecting Radiation Dose (and Image Quality)
ABC = automatic brightness control
higher kVps on the x-ray tube
more x-ray tube current (higher mA)
opening the aperture to increase the brightness
longer x-ray pulse width
less x-ray beam filtration
or some combination of these
factors
Fluoroscopy
ABC systems
X-ray beam kVp and filtration
Aperture smaller aperture blocks more light from output phosphor,
and decreases dose rate (the aperture is used to balance an acceptable
amount of noise w/ an acceptable level of patient dose rate)
Pulse vs continuous fluoro
Conversion gain as an II ages, the amount of light produced in the
input phosphor decreases and the conversion gain decreases this
results in GREATER RADIATION DOSE because the II is less efficient
Geometry
Decreased SID dose
Image receptor close to patient
FOV selection
II system: smaller (mag) FOVs increase the
dose
FPD: may not increase x-ray output
c.f. AAPM/RSNA Web Module: Fluoroscopy systems. Section IX.B.
Fluoroscopy
Radiation Dose: II vs FPD
Radiation Dose II Systems FPD Systems
If FOV is reduced (mag mode) increases the radiation dose
not necessary to increase
the dose
Increasing the SID increases the radiation dose
Adding filtration (e.g. Cu)
preferentially removes low energy x-rays, therefore decreasing
the dose
Smaller aperature (large F)
increases the radiation dose
(aperature balances acceptable
amount of image noise with an
acceptable level of patient dose)
n/a
Increasing kVp reduction in radiation dose (more x-rays penetrate the patient)
Reducing the pulse rate reduction in radiation dose
Decreasing conversion gain
increases the radiation dose (in
aging IIs)
n/a
c.f. AAPM/RSNA Web Module: Fluoroscopy systems. Section IX: A-J.
Review Questions
An interventional radiologist performed 5000 fluoroscopically
guided procedures last year. His annual occupational exposure
was reported as background. What is the most likely
explanation?
A. All procedures were performed remotely from the x-ray control
room.
B. His badge was worn under a 0.5mm lead apron.
C. The radiologist never wore his radiation badge while working.
D. The departments control badges were stored in the
interventional control room.
E. There was a persistent failure at the radiation badge company.
Review Questions
Which one of the following scenarios will result in the highest skin
dose to the patient?
A.
B.
C.
D.
Short SSD plus large SID results in higher patient dose. Use of the
grid also requires higher patient dose.
Questions?

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