I.1.

QUALITY CONTROL OF THE X-RAY FLUOROSCOPY

EQUIPMENT IN THE PERIOD OF THEIR CLINICAL
USE - METHODS AND FIRST RESULTS
A. Dimov, J. Vassileva
National Centre of Radiobiology and Radiation Protection, Sofia, Bulgaria
Abstract
The Quality Control (QC) routine performance tests of the fluoroscopy equipment are
an irreversible element of the Quality Assurance (QA) and Patient Protection (PP) system.
The results from these tests may be helpful in identifying and quantifying: changes in system
performance due to component failure or drift, programmed changes in system performance
due to upgrades - software, a new spectral filter capability, pulsed fluoroscopy dose/pulse
settings, etc. This gives a potential for optimization – good QA should reveal the full potential
of the system and its optimization.
Some basic legislative requirements, physical methods and approaches used in the QC
of the fluoroscopy equipment are heard. Results of their practical application are presented.
Key words: quality assurance, quality control, fluoroscopy equipment, patient protection
Introduction
The X-ray fluoroscopy procedures often give significant radiation doses to patients. In
Bulgaria the contribution of the X-ray diagnostics to the over background exposure of the
population is about 80% with average annual effective dose per capita of 0,85 mSv in the year
2000, as the number of the fluoroscopy examinations is twice more than the number of the
radiographs performed [1]. The introduction of Quality Assurance (QA) programme is very
important and valuable radiation protection tool in achieving of continual production of
optimal quality images with the minimum necessary dose to the patient. Various publications
providing information on quality assurance, commissioning and constancy checking of
fluoroscopy systems exist [2, 3, 4]. From this information it is apparent that there is a need for
harmonisation within Europe. The new Bulgarian Ordinance of radiation protection of the
individual at medical exposure is expected to come into force at the beginning of 2005. Its
main purpose is to protect the population from the dangers connected with the use of the
ionising radiation in various diagnostic and therapeutic applications in medicine according to
the requirements set in the EC 97/43 EURATOM Directive [5]. At the same time in Bulgaria
still there is not adopted protocol for performance of QC tests of the fluoroscopic equipment.
The inappropriate equipment might lead to increased dose to patients and staff, insufficient
image quality and, for interventional radiology, to inefficacious procedures with a potential
for occurrence of deterministic effects. The aim of this paper is to review some of the most
popular methods for QC testing and to propose a protocol for Quality Control on which the
first National Quality Control (performance) study of the fluoroscopic equipment can be
based. Once performed such study will provide essential information for developing of
National ALARA based criteria for acceptability of the fluoroscopic installations with
relevant remedial and suspension level tolerances.
Materials and methods
The QC procedure starts with the X-ray tube and generator measurements. Further test
are carried out for assessment of the system for automatic brightness control (ABC) and the
image quality (IQ).
The tube and generator tests and the dose measurements were performed using two types of
dosimeters with the following electrometer-chamber/detector combinations:
(1) Unidos E (PTW Freiburg) with 112 cc ionisation chamber type TW 77335 and
 (2) Barracuda (RTI Electronics) with multipurpose detector - MPD.
For the patient skin entrance dose rate measurement a 20 cm thick PMAA body
phantom was used. A set of Al filter was used for the X-ray beam half value layer (HVL)
measurements and a star pattern for assessment of the focus size. At other dose measurements
and image quality tests a 1 mm Cu filter was attached to the tube light beam diaphragm. A
0.35 mm Al equivalent Lead apron, fold in two was used for the Maximum patient entrance
surface dose rate assessment.
For the fluoroscopy image quality (IQ) assessment Leeds type test objects SW4, FSG4,
LCD4, Hüttner type 18, SSM4, TCD4 and FL 18 were used [6]. For the focus to detector
(chamber) distance measurements a standard tape measure was used.
The QC protocol was tested on a fluoroscopy unit Philips Telediagnost with high
frequency generator Philips Optimus and X-ray tube Philips type 98062067002. One standard
fluoroscopy screening programme and 13, 18 and 25 cm nominal radiation to Image
Intensifier field’s sizes are available on this unit. The results of the tests are given in the tables
in the results section, as the nationally adopted accepted tolerances were indicated ether in the
column ‘Tolerance’, either in the column ‘Expected’.
1. Tube and generator measurements. The X-ray emission performance was measured
with the dosimeter of combination (2) at 91.5 cm distance from the tube focus. The
measurements ware performed at the use of the broad focus, because it is the only clinically
used.
2. Assessment of the System for Automatic Brightness Control (ABC)
Image Intensifier Entrance Dose Rate. The unit was switched to auto mode with both
kV and mA automatically set. The electrometer - chamber combination was used. The
chamber was placed directly on the entrance surface of the image intensifier (II). Screening
was carried out and the dose rate was recorded together with delivered mA and kV for each of
the available field sizes. The test was carried out at focus to II distance of 100 cm and focus to
chamber distance of 99.5 cm with 1 mm Cu attached to the tube diaphragm. The dose rate at
the chamber was scaled to the surface of the II using the inverse square law. The dose rate
was then compared to the recommended maximal value of 1µGy/s (should never exceed 2
µGy/s).
Entrance Surface Dose Rate (Patient Skin Entrance Dose Rate). The same set up as in
the previous measurement was used but using for the dose measurements both electrometer -
chamber and electrometer – semiconductor detector combinations. The chamber and the
detector were placed consequently on the entrance surface of the 20 cm PMAA body
phantom. The dose rate was measured for various field sizes with and without 1 mm Cu
filtration added.
Maximum possible entrance surface dose rate. A lead apron covering the II was used
and the dose rate was measured with no Cu filter attached on the tube.
3. Assessment of Fluoroscopic Image Quality. The assessment of the image quality is
based on subjective tests using standard image quality assessment phantoms [6]. Most of the
measurements were for each of the three available field sizes at focus to Image Intensifier
distance of 100 cm (indicated on the control panel of the unit) using the only screening
programme available. The grid was left in situ during all the measurements.
Monitor Adjustment. 1 mm Cu was attached to the tube. The SW 4 test object was put
on the image intensifier and screened using a "calibration beam" (70 kVp) and normal field
size. The monitor was adjusted and then the phantom was screened for the other field sizes.
The screening parameters were recorded. The number of visible steps was counted. Notes
were made whether the black and white circles, on the white and black square respectively,
are visible and circular. If not all the steps are visible the monitor settings should be adjusted
until they are or until the best brightness and contrast is achieved. In case when not all the ten
steps are seen, their actual number is recorded.
Image Geometry and Sizing. The FSG4 object was screened and 1 mm Cu was attached
to the tube diaphragm. The number of squares seen on the monitor was counted in vertical and
horizontal direction and the appeared distortions were recorded. The measured field size was
compared to the nominal value. The diagonals of the central square DC and the largest square
in the field DL were measured. The distortion is defined as:
Distortion = (DL/( n × DC) - 1) × 100 %, where n is the number of intervals per side in the
largest square.
Noise. The N3 test object was screened using the 1 mm Cu added filter. The number of
the visible disc objects was counted. This number is compared to the commissioning number
for the same unit. The relevant contrast level in % is assessed and compared to the previous
values.
Unsharpness and Spatial Resolution. The Hüttner test object was attached to the image
intensifier and orientated 45° to the monitor grid lines. The test was performed under soft
beam conditions with no copper used. The number of resolved groups was counted and the
corresponding resolution was recorded. The resolution is compared to the expected value.
Overall Image Quality. The TCD4 test object was screened and 1 mm Cu was used as
additional attenuator. The number of detectable discs for each group was recorded and
compared to the expected values.
Radiation to image field size. Equipment used for fluoroscopy should be provided with
the means, preferably automatic, to confine the radiation beam within the image reception
area whatever the distance of the X-ray tube from the image receptor. Radiation field size was
measured using a standard film cassette and image field size was measured using FSG4 test
object.
Image quality. FL 18 with 1 mm Cu was used for assessment of the relevant parameters
exactly in the same way as with SW4, LCD4 and Hüttner test object.
Focusing. The uniformity of the focus was tested using SSM4 test object with no added
copper filtration.

Results and discussion

The results from the tube and generator tests are presented in Table 1. The results from
the assessment of the ABC system are given in Tables 2, 3 and 4 and from the image quality
assessment - in Tables 5 to 11 respectively. In Tables 2, 8 and 10 as base values the results
from previous measurements (December 2003) are used.
As it is seen from Table 1, the tube and generator performance is within the accepted
tolerances and is generally good. The effective size of the focus is changed from the stated,
but is still inside the tolerance level.
The II dose rate is higher at a smaller field size (Table 2). A smaller field size
produces a greater magnification of the image. At smaller field size fewer photons intercept
the II surface at the same energy flux, so therefore the beam intensity (kV and mA) is
increased by the ABS to obtain an acceptable image quality. The unit is below the maximum
tolerated dose rate of 1 µGy/s for all field sizes.
The patient skin entrance dose rate (Table 3) and the maximum possible entrance dose
rate (Table 4) are within the recommended tolerances. The results obtained with both
dosimeters are totally comparable. Further the possibility to use semiconductor detectors for
quick inspection checks appear to be justified.
 Table 1. X-ray Tube and Generator Performance
Parameter Measured Tolerance Accept?
Output at 80kV (µGy/mAs at 1m) 54,21 26<op<69 Yes
Baseline output at 80kV (µGy/mAs at 1m) 54,21 Yes
Variation from baseline (%) 0,0 < +/- 20% Yes
The output consistency (%): 0,2 < 15 Yes
The output variation with mA/mAs (%): 1,5 < 10 Yes
The output variation with ms (%): 1,2 < 10 Yes
The power, n, of the output variation with kV (BF): 1,9 1.7<n<2.5 Yes
The kilovoltage consistency (%): 0,2 < 10 Yes
The max. kilovoltage inaccuracy (BF) (%): 6,3 < +/- 10 Yes
The timer consistency (%): 0,9 < 10 Yes
The maximum timer inaccuracy (%): 8,6 < +/- 15 Yes
Measured Half value Layer in mm of Aluminum 3,1 n/a
Inferred total filtration in "mm of Al equivalent" 3,2 > 2,5 Yes
Focal Spot Nominal Size BF (mm): 1,3
Effective focal spot sizes in mm (BF) 1,69 < 1.8 Yes
Table 2. Image Intensifier Dose Rates
II field Read kV Read mA Dose Rate (nGy/s) Deviation Tolerance Accept
size Measured @ II Baseline (%)
25 64 0,9 470,000 465,312 450,797 3,2 baseline Yes
18 65 1 530,000 524,713 548,882 -4,4 +/- 25% & Yes
13 69 1,2 782,000 774,200 750,998 3,1 < 1µGy/s Yes
Table 3. Entrance Surface Dose Rate
With Unidos
II field Read kV Read mA Dose rate Remedial Accept
size (µGy/sec) (mGy/min) level
25 84 2,4 386,00 23,16 Yes
18 89 2,7 467,00 28,02 50 mGy/min Yes
13 101 3 565,00 33,90 Yes
With Barracuda
II field Read kV Read mA Dose rate Remedial Accept
size (µGy/sec) (mGy/min) level
25 89 2,7 354,5 21,27 Yes
18 102 3 511,2 30,67 50 mGy/min Yes
13 110 3 548 32,88 Yes
Table 4. Maximum Possible Entrance Dose Rate
Read Read Measured dose rate Tolerance Accept? When Electrometer
kV mA (mGy/min) (mGy/min) measured? used
110 3 36,06 100 Yes Now Unidos
110 3 36,78 100 Yes Now Barracuda
Table 5. Monitor Adjustment
Nominal Read Read No. of Lead
Monitor contrast and brightness adjusted?
field size kV mA steps periphery
25 64 0,9 10 0 - ellipse yes
18 66 1 10 0 - ellipse no
13 70 1,3 10 0 - ellipse no
Table 6. Image Geometry and Sizing
Nominal Measured field size Expected Integral Distortion Comments Accept?
field size width height field size (%)
25 27 27 4,9 s-distortion Yes
> 21,3 x
18 22 22 21,3 1,4 slight s-distortion Yes
13 16 15 2,3 slight pin-cussion Yes
The Image geometry (Table 6) tests indicate appearance of s- and pin-cushion
distortion. The first is due to the influence of the earth magnetic field to the image formation
and the last is due to internal construction of the II and the optical aperture. The results from
the Radiation to image field size tests (Table 9) show a proportion that is slightly outside the
recommended tolerance for the 18 cm field. Table 7. Noise
Nominal Read Read Detail number Contrast (%) Accept?
field size kV mA Measured Baseline Measured Expected (%)
25 69 1,2 9,5 9,5 3,455 < 4,0 Yes
18 71 1,3 11 11 2,57 < 4,0 Yes
13 69 1,2 11 11 2,57 < 4,0 Yes
Table 8. Unsharpness and Spatial Resolution
Nominal Read Read Visible Group Spatial Frequency (lp/mm) Accept?
field size kV mA Current Baseline Tolerance Measured Expected
25 50 0,4 5 4 0,80 >1 No*
Baseline - 2
18 47 0,4 6 5 groups 0,90 >1,4 No*
13 52 0,5 9,5 9 1,33 >2 No*
Table 9. Radiation to Image Field Size
Nominal Radiation field size Image field size Radiation field size Tolerance Accept?
field size height width height width Image field size
25 28,7 29,6 27 27 1,10 Yes
ratio of areas >
18 25,8 25,4 22 22 1,17 No*
1.15
13 17,3 17 16 15 1,13 Yes
Table 10. Image Quality using FL 18
Read kV and mA Spatial resolution Contrast
Field size
Baseline Measured Baseline Measured
kVp mA kVp mA (lp/cm) (%) (lp/cm) (%)
25 cm 67 1,1 68 1,1 0,8 3,3 0,8 3,3
18 cm 66 0,9 70 1,3 0,9 3,3 0,9 3,3
13 cm 71 1,3 71 1,3 1.33 2,7 1,19 2,7
Table 11. Overall Image Quality with TCD4
Field size: 25 18 13
kV, mA: 69 / 1.2 71 / 1.3 69 / 1.2
Visible detail number Visible detail number Visible detail number
Row Current Baseline Current Baseline Current Baseline
A 4 4 4 4 4 4
B 4 4 4 4 4,5 4,5
C 3 3 3 3 3,5 3,5
D 3 3 5 5 5,5 5,5
E 3 3 4 4 5 5
F 3 3 3 3 4 4
G 0 0 0 0 5 5
H 0 0 0 0 3 3
J 0 0 0 0 0 0
K 0 0 0 0 4 4
L 0 0 0 0 2 2
M 0 0 0 0 0 0
Tolerance: Baseline - 2 groups
Accept: Yes Yes Yes
The values measured during the IQ tests should be considered as a base values (Table
5, 7, 11). They should be compared to values measured at the future constancy tests. The
future measured values may indicate a lower image quality than the base ones. This may be an
indication of deterioration of the image quality, but it also can be due to the inexperience of
the observer. As general the image quality is better at a smaller field size due to the decreased
noise (higher dose rate).
The performance of the focusing of the image, tested with the SSM4 test object was
generally weak. During the tests the following details were seen: at 25 cm field the mesh was
not seen, there were two vertical lines and a dark spot in the centre of the image; at the 18 cm
field the image was not clear and dark spots were seen in it’s right up and left down part; at 13
cm magnification, the mesh was seen but with darkening of the right up and left up.
A difference in low contrast sensitivity measured with LCD4 and FL 18 was found
(Tables 7 and 10). Probably it is due to the more-precise scale of LCD4, but it should be
studied at future tests in order to minimise the influence to the uncertainty connected with the
subjective assessment. The measured low contrast sensitivity was within the accepted
tolerance, but it is outside the optimal values for modern systems.
The spatial resolution measured with FL18 and Hüttner type 18 test object alone, was
the same, but it is outside the accepted tolerances (Tables 8 and 10). Compared with the
previous test (made in December) no change in the number of groups visible was found, but
the noise is more then the optimal level. The system behaves stabile in time, but the results
from the measurements of the low contrast sensitivity, the limiting spatial resolution and the
uniformity of the focus show weak performance which might be connected with possible
misalignment of the intensifier optics and camera tube. Another possible reason is a play at
the rotation of the tube anode due to problem with anode bearings.

Conclusion
1. The tube and generator performance of the system is within the recommended
tolerances and is generally good, but some further more precise measurements of the
focus size may indicate a possible wearing of the anode and are recommended.
2. The actual reason for the measured weak or suboptimal performance in the low
contrast sensitivity, limiting spatial resolution, uniformity of the fluoroscopy image
focusing, image geometry and sizing have to be investigated and corrected by a
qualified service engineer.
3. For the routine performance tests and for quick inspection checks a dosimeter with
semiconductor detector can be successfully used instead of ionisation chamber
dosimeter.
4. Some basic parameters that can give appropriate measure of the image quality can be
assessed easy with a combined phantom similar to FL 18. The last is recommended for
use from the Health Inspectorates and from the local hospital staff at quick inspections
and routine performance tests respectively. The other IQ tests need more specialised
training of the medical physicists and availability of full range IQ standard test objects
and have to be performed at the commissioning of the fluoroscopy units.
5. The explored methods for QC tests have to be applied on more units typically used in
the country. The results may indicate a need for revision of the nationally adopted
acceptability criteria for the fluoroscopy equipment.

References:
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