MEDICAL IMAGING

Academic year: 2022/2023

Course duration: 15hours
Course lecturer: Ian Kinkoh
By the end of this subject student should be able to:
1. Explain the basic principles of the major medical imaging techniques;
2. Explain the mode of operation and medical applications of the major medical imaging
techniques
3. Understand the advantages and disadvantages of the major imaging techniques, including
Potential hazards for patients;

Introduction
Medical Imaging is the technique and process of creating visual representations (images) of the
Interior of a body, i.e., of internal structures that are hidden by the skin and bones. It is used for
sake of clinical analysis (e.g., to diagnose a disease) and medical intervention (e.g. to treat a
disease). It is also used to establish a database of normal anatomy and physiology to facilitate the
identification of abnormalities.

Image Formation
Imaging can be regrouped according to how the image is formed. There are two types namely:
1. Reflection Mode: The image is recreated based on the amount of signal reflected by the
tissue/organ of interest.
2. Transmission Mode: The image is recreated based on the amount of signal passing through
the tissue/organ of interest.

Image Quality
Different imaging modalities produce images of different quality. One aspect that affects the
Choice of one modality over the others is the required image quality. Three parameters define the
quality of a medical image:
1. Contrast ⇒ It is the difference between the intensity (or color) of the image and its
Surrounding.
2. Resolution ⇒ it is the ability to resolve any two adjacent points of an image. It defines the
smallest possible dimensions of a point that can be detected.

What is a wave?
In physics, mathematics, and related fields, a wave is a disturbance of a field in which a physical
Attribute oscillates repeatedly at each point or propagates from each point to neighboring points,
or seems to move through space. The waves most commonly studied in physics are mechanical
and electromagnetic. An oscillation is the repetitive variation, typically in time, of some measure
about a central value or between two different states.

Ultrasound waves
Ultrasound is sound waves with frequencies higher than the upper audible limit of human
hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties,
IAN KINKOH 1
except that humans cannot hear it. Ultrasound is used in many different fields. Ultrasonic devices
are used to detect objects and measure distances. Ultrasound imaging or sonography is often
used in medicine.

Electromagnetic waves
Also EM waves, refer to waves that are created as a result of vibrations between an electric field
and a magnetic field. In other words, EM waves are composed of oscillating magnetic and
electric fields.

The Anatomical Terms of Location

The anatomical terms of location

Medical imaging planes

IAN KINKOH 2
Axial plane OR transverse plane: perpendicular to the body long axis
Sagittal: bisects the left from the right side [from new latin sagitta = arrow]
Coronal: bisects the front from the back [from latin corona = crown]

RADIATION MEDICAL IMAGING

Radiation is energy emitted from a body called the source that is transmitted through an
intervening medium or space and is absorbed by another body. Radiation is transmitted in the form
of waves.

Radiation medical imaging technique makes use of high energy electromagnetic particles (e.g. x
rays) to produce images used for medical diagnosis. Radiations can be either ionizing or non-
ionizing.

Non-ionizing radiation has longer wavelength/lower frequency and lower energy examples
includes ELF (extremely low frequency), Radio Frequencies, B and Microwave Frequencies,
Lasers, and Infrared, Visible Spectrum, and Ultraviolet rays.

Ionizing radiation has short wavelength, high frequency and higher energy. Ionizing Radiation
has sufficient energy to produce ions in matter at the molecular level. Ionizing radiation is emitted
from radioactive atomic structures as high energy electromagnetic waves (e.g. gamma and x-rays)
or as actual particles (alpha, beta, neutrons). Gamma Rays and X-rays Penetrate the Body Easily.
Alpha particles can be stopped by a sheet of paper, Beta particles are stopped by plastic, (if the
matter is a human body significant damage can result to the skin). Gamma rays can be stopped by
a block of lead, Alpha and Beta Particles are blocked by the skin with Beta Particles penetrating
more deeply with the potential to cause burns. This is to say that non-ionizing radiation can cause
injury to humans but the injury is generally limited to thermal damage i.e. burns examples of
radiation medical imaging technique includes X-ray, CT scan, angiogram, fluoroscopy

Imaging modalities
Method information carrier Note
high -frequency pressure backscattering / reflection imaging
Ultrasound imaging waves
X-ray imaging (projection emission imaging
radiography)
ionizing radiation
Computed tomography:
CT, C-arm

Nuclear imaging: SPECT, transmission imaging

PET

Magnetic resonance nuclear spin precession magnetic resonance imaging

imaging (MRI)

IAN KINKOH 3
 X-RAY

X-rays are the oldest and most commonly used medical imaging technique. X-rays was discovered
by Wilhelm Conrad Roentgen in Wurzburg, Germany, On November 8, 1895 and it was first used
to image human tissue in 1896. X-rays use ionizing radiation to produce images of a person’s
internal body structure by sending beams through the body. These are absorbed at different levels
depending on the density of the tissue. X-ray radiation can generate three kinds of medical images;
conventional X-ray imaging, angiography and fluoroscopy. X-ray imaging generates an image of
a localized part of the body, which will be analyzed for anatomical abnormalities.
This kind of imaging usually evaluates; the skeletal system, oral cavity (bone and teeth), ingested
objects, the lungs, the breast (Mammography), the digestive system. X-rays loses a certain amount
of energy when they pass through different materials. The energy loss depends on the absorption
behavior of the material. For example if X-rays pass through 10cm of water, they lose less energy
than if they would pass through 10cm of bone. The reduction of energy is caused by absorption
which is the main principle of X-ray imaging. Generally speaking, X-ray radiography measures
the amount of energy loss. Because this energy loss differs for the different materials, we can see
a certain contrast in the image. X ray image shows high intensities for soft tissue and lower
intensities where the X-rays passed through bones.

Harmful Effects of X-Ray

A point of rapid development is the awareness that X-rays can also be harmful. High energies
emitted to the body during an X-ray acquisition can lead to ionization. That means the radiation
changes the atomic structure of the tissue which can potentially lead to an increased risk for the
developing cancer. Here, deoxyribonucleic acid (DNA) becomes damaged by the radiation. In
most cases, the DNA will be repaired by the cell itself. Yet, the repair process sometimes fails
which in some cases leads to an unregulated division of cells that might result in cancer.

IAN KINKOH 4
Importance of X-Ray

X-ray radiography is useful in detecting or in the diagnosis of medical conditions such as; Bone
fractures, Infections (such as pneumonia), Calcifications (like kidney stones or vascular
calcifications), some tumors, Arthritis in joints, Bone loss (such as osteoporosis), Dental issues,
Heart problems (such as congestive heart failure), Blood vessel blockages, Digestive problems,
Foreign objects (such as items swallowed by children).

IAN KINKOH 5
IAN KINKOH 6
Radiation protection and safety

Radiation protection and safety procedures have been established to ensure the protection & safety
of the staff, patients and their relatives during x-ray imaging and to ensure that fertile and pregnant
women are not exposed to radiation accidentally or unintentionally. Radiation safety is enforced
to ensure that both patients and radiation health workers are not exposed to unnecessary radiation
through the use of proper techniques, equipment and shielding materials

Rules on Protection

• Adequate radiation protection to all people in the area. In x-ray section, lead barriers,
gonadal shield and lead gown are used.
• Radiographers should ensure that patients, relatives and staff are properly instructed
before an x-ray exposure is made.
• No x-ray examination should be carried out without a written request from the requesting
physician or a request signed by authorized personnel
• For inpatients, check the patient chart before printing the request to ensure that the exam
requested is correct.
• For female patients of childbearing age, the last menstrual period (LMP) should be
recorded on the x-ray request
• If the patient is pregnant but the exam is a necessity, consult the radiologist. Provide a
shield for the patient and require a signed consent prior to proceeding with the exam.
Abdominal and pelvic x-ray should not be performed. The radiologist will consult the
referring physician to discuss possible alternatives or modifications of the exam to
minimize exposure to the fetus/embryo
• Special precautions should be adopted in the x-ray of pregnant women, and justification
of the requested examination should be obtained from the radiologist prior to the
procedure
• All women of reproductive age should have abdominal x-ray examinations taken within
28 days of the first day of menstrual period.
• Using high KV techniques for chest x-ray procedures, good quality film and less
radiation dosage to the patient.

IAN KINKOH 7
 Fast Facts on X-Rays

• X-rays are a naturally occurring type of radiation.

• They are classified as a carcinogen.
• The benefits of X-rays far outweigh any potential negative outcomes IF PROPERLY
USED.
• CT scans give the largest dose of X-rays compared to other X-ray procedures.
• In X-rays, bones show up white, and gasses appear black.

Some of the main benefits are as follows:

• Non-invasive: An X-ray can help diagnose a medical issue or monitor treatment

progression without the need to physically enter and examine a patient.
• Guiding: X-rays can help guide medical professionals as they insert catheters, stents, or
other devices inside the patient. They can also help in the treatment of tumors and remove
blood clots or other similar blockages
• Unexpected finds: An X-ray can sometimes show up a feature or pathology that is
different from the initial reason for the imaging. For instance, infections in the bone, gas
or fluid in areas where there should be none, or some types of tumor.

Some specialized x-ray imaging techniques

1. Mammography: this X-ray examination used in diagnostic screening for breast cancer. It
is used by radiologist or surgeon before biopsy (removal of cells or tissue for examination),
or lumpectomy (surgery to remove e.g. a tumor). During the procedure the radiation used
for mammography tends to have a lower photon energy than that used for bone and harder
tissues. Globally, breast cancer is the most lethal form of cancer for women (106
cases/year)
2. Fluoroscopy: Provides real-time images using x-rays
Mechanism of imaging: X-ray source → patient → fluorescent → recorder
3. Angiography: this is used to visualize the inside of blood vessels and organs. Ancient
Greek: angeion = “container”, grapho = “I write”. Angiography images are hence made
while injecting contrast medium into the bloodstream the Image produced includes all
overlying structures besides the blood vessels and this is useful for determining
anatomical position of blood vessels. The Blood has the same X-ray density as
surrounding tissue. An iodine-based contrast is injected into the bloodstream and
images are taken as it travels through the blood stream. Angiography is used to find:
– Aneurysms (abnormal blood-filled swellings of an artery or vein, resulting from a
localized weakness in the wall of the vessel)
– Leaks
– Thrombosis (blood-clots that form and cause obstruction of the blood vessel), etc
The X-ray images may be:
– Still images, displayed on a fluoroscope or film
– Video sequences (25–30 frames per second)

IAN KINKOH 8
 Retinal angiography: commonly performed to identify vessel narrowing in patients with
e.g. diabetic retinopathy and macular degeneration [retina = light sensitive tissue lining
the eye inner surface, macula = yellow spot near retina center responsible for central vision]

COMPUTED TOMOGRAPHY (CT)

Computed = use of computer

Tomography: Greek word tomos means "slice", graphy means "write". CT is an examination that
uses X-ray and computer to obtain a cross-sectional image of the human body. This is a medical
imaging technique in which series of X-ray, controlled by a computer create cross-section
images of the inside of the body, including bones, blood vessels and soft tissues. Images are
produced in cross-section because the machine used is rotatory. CT scan also commonly referred
to as computed axial tomography (CAT). CT scan combines multiple X-ray images taken from
different angles. This produces detailed cross-sectional internal images in a 3 dimensional frame.
The resulting images provide greater information than regular X-rays, allowing doctors to
examine individual slices within the 3-D images. Contrast agents are commonly used in
combination with CT scans to perform angiographies and other specific tissue examinations. CT
as an imaging technique was described by Cormack in1963. In 1971, the first CT system was
built by Sir Godfrey Newbold Hounsfield and Allan McLeod Cormack (the prototype made 160
parallel readings in 180 angles, with each scan taking 5 minutes). The first CT scanner for
medical use dates from 1972 by Hounsfield. Hounsfield and Cormac shared the 1979 Nobel
Prize for this discovery.

USES OF CT SCAN
CT Scans are often used to evaluate:

• Organs in the pelvis, chest and abdomen

• Colon health (CT colonography)
• Presence of tumors
• Pulmonary embolism (CT angiography)
• Abdominal aortic aneurysms (CT angiography)
• Spinal injuries
• Cardiology.
IAN KINKOH 9
Technological improvements in CT such as dose modulation acquisition techniques and
iterative reconstruction algorithms dramatically reduce the required X-Ray dose, improve
hospital efficiency and clinical effectiveness and reduce costs

PARTS OF A CT SCAN MACHINE

➢ Gantry or scanner system: this is comprised of

1. X-ray tube which generates x-ray beams
2. Detector system: detects the x-rays passing through the patient's body.
3. Collimator: narrows the beams of x-rays
4. Filters: these are used to filter some rays from entering the patient's body that may
be harmful
➢ Patient's table
➢ Computer (operation control)

TYPES OF CT SCAN

1) Spiral CT; Spiral computed tomography is a type of 3D CT scan. The x-ray machine scans the
body in a spiral path. This allows more images to be made in a shorter time than with older CT
methods. A dye may be injected into a vein or swallowed to help the organs or tissues show up
more clearly on the x-ray. Spiral CT scan also creates more detailed pictures and may be better at
finding small abnormal areas inside the body. It may be used to help diagnose disease, plan
treatment, or find out how well treatment is working. Also called helical computed tomography.
2) Electron beam tomography (EBT); Electron-beam computed tomography (EBCT) is a fast
test to look for calcium build-up in the heart's arteries. It uses an electron gun to scan the chest.
EBCT may be used to screen people for coronary artery disease (CAD). It can help assess the risk
of having a heart attack in the future. EBCT may be used to screen people for coronary artery
disease (CAD). It can help assess the risk of having a heart attack in the future.
3) CT perfusion imaging; Computed tomography (CT) perfusion uses special x-ray equipment to
show which areas of the body are adequately supplied with blood (perfused) and provides detailed
information about blood flow to the body part. CT perfusion is fast, painless, noninvasive and
accurate. It's a useful technique for measuring blood flow to the brain, which may be important for
treating stroke, brain blood vessel disease and brain tumors.

When X-rays pass through the human body, some of the rays are absorbed and some pass through
the body to produce an image. In plain X-ray imaging, the film directly absorbs penetrated X-rays.
In CAT scanning, an electronic device called a "detector array" absorbs the penetrated X-rays,
measures the X-ray amount, and transmits the data to a computer system. A sophisticated computer
system, in turn, calculates and analyzes data from each detector in each level, and finally
reconstructs multiple, two- dimensional, cross-sectional images.

Uses of CT scan

IAN KINKOH 10
CT scan is very important in the diagnosis of injuries from trauma, bone fractures, tumors and
cancer, vascular and heart diseases, infections and for guided biopsies.

A CT of the brain can reveal tumors, blood clots, hemorrhages, or other abnormal anatomy. A
series of computerized images of the brain at various levels are taken to reveal normal anatomy
or any abnormality.

CT scan evaluate acute cranial-facial trauma

Determine acute stroke

Evaluate suspected intracranial hemorrhage

Evaluate headache Determine if there is abnormal development of the head and neck Tumors,
clots

PATIENT PREPARATION FOR CT SCAN

Respiration: shallow breathing

Positioning: Supine

Head immobilized

Arms along the sides.

Fasting for 4 Hours before the examination.

Respiration suspended

No swallowing.

IAN KINKOH 11
IAN KINKOH 12
 MOLECULAR IMAGING
Molecular Imaging is a diagnostic tool where metabolic processes can be visualized by
administering small amounts of radioactive pharmaceuticals to patients. These accumulate in a
specific part of the body in a controlled way. Unlike other ionizing radiation techniques, which
IAN KINKOH 13
can only generate anatomical images, this technique generates functional images. Some conditions
initially have a physiological effect, rather than an anatomical change in the body. Molecular
imaging allows for an earlier diagnosis. Combining molecular imaging with CT or MRI images
can provide clinicians with superior images. Two specific technologies are used in nuclear
medicine, namely Positron Emission Tomography (PET) and Single Photon Emission
Tomography (SPECT). PET and SPECT are types of nuclear imagine techniques that provide
physicians with information about how tissues and organs are functioning. In 1976 the first SPECT
and PET scanners were developed going through 5 generations until what is in the market today.
These two techniques generate images that reveal the metabolism of the body, or the behavior of
certain particles, but cannot generate images of the anatomical structures. In order to provide a
better image for the clinicians, molecular imaging can be combined with CT or MRI images. When
the images are put together, the PET or SPECT images will be related to the anatomical structures
obtained from the CT or MRI images.

PET and SPECT are often used as diagnostic and follow up images for:

• Neurological diseases such as Alzheimer’s and Multiple Sclerosis.

• Cancer.
• Heart disease.

Angiography uses X-rays in combination with a contrast agent (chemical substances used to
enhance specific structures in images) in order to visualize blood vessels, particularly the coronary
arteries.

Fluoroscopy uses X-rays to visualize the internal structure in real-time, providing moving images
of the interior of an object, such as hearts beating or throats in the process of swallowing

PET SCAN

IAN KINKOH 14
Single photon emission computed tomography (SPECT)

Mostly used for study of blood-flow, by injection of a radiopharmaceutical into the bloodstream. It may also ingest
or inhale the radiopharmaceutical. The Image obtained by gamma camera is a 2-D view of 3-D distribution of a
radionuclide. SPECT imaging is performed by using a gamma camera to acquire multiple 2-D image. SPECT
images are collected by pinhole gamma camera rotating around patient. Projections are acquired at defined points
during the rotation, typically every 3-6 degrees. A full 360◦ rotation gives optimal reconstruction:

IAN KINKOH 15
NON IONIZING RADIATION

There are other medical imaging techniques that do not use ionizing radiation, using instead
Magnetic fields, radio frequency or ultrasound radiation, that up to the moment have been proved
to cause limited harm to the human body, therefore reducing the collateral damage to the
surrounding tissue that is caused by ionizing radiation.

ULTRASOUND
What is ultrasound?
Ultrasound is defined as high-frequency sound waves of 20 thousand to 1 million Hz (cycles per
second) or greater. (Each peak in a sound wave represents one cycle.) Diagnostic ultrasound
operates between 3.5 and 10 million Hz (3.5 and 10 MHz).
Ultrasound or echography is an imaging test whereby very high frequency sound waves
introduced to the body through the use of a machine produce images of structures within the
body. The pictures produced are known as sonogram.
Ultrasound have different applications, it can be used for therapy and muscle stimulation or as a
diagnostic tool in medical imaging using an ultra-sonographer. Diagnostic ultrasound, also
known as medical sonography or ultrasonography, uses high frequency sound waves to create
images of the inside of the body. The ultrasound machine sends sound waves into the body and is
able to convert the returning sound, echoes, into a picture. The first image created with this
technique was published in 1952. Ultrasound technology can also produce audible sounds of
blood flow, allowing medical professionals to use both sounds and visuals to assess a patient’s
health.

Ultrasound is often used to evaluate:

• Pregnancy
• Abnormalities in the heart and blood vessels
• Organs in the pelvis and abdomen
• Symptoms of pain, swelling and infection

How does ultrasound work?

Ultrasound is created by the high-frequency vibration of a crystal located in the ultrasound
transducer which is a piece of equipment about the size of a small cell phone that fits easily into
the hand. The soft curved end of the transducer is placed on the patient, and gel is used to
improve its contact with the skin. During the scanning process, the crystal is stimulated
electronically to vibrate. This occurs in an instant and the crystal then becomes a listening device
for the returning echoes from ultrasound reflected back by body tissues. These returning echoes
are converted to a gray scale for the creation of an ultrasound image

IAN KINKOH 16
How is an image created with ultrasound?
As the ultrasound energy travels through tissues of the body, it is scattered, transmitted, or
reflected back to the transducer. Ultrasound that is scattered does not help to create an image.
Ultrasound that is transmitted produces an echo-free area on the image. Fluid such as ascites, bile
within the gallbladder, and serous water within a cyst all appear as sonolucent (echo-free and
black on the film) areas on the ultrasound image. Reflected ultrasound creates a density on the
ultrasound image (gray or white on the film).The difference in how much ultrasound a given
tissue reflects allows us to see individual structures. For example, the pancreas reflects more
ultrasound (is more echogenic) than the liver, the liver reflects more than the spleen, and the
spleen reflects more than the kidneys.

Important term 1 “Increased through transmission”

When ultrasound passes through a fluid medium, the intensity of the sound energy is not
diminished. Therefore, tissues behind the fluid collection are more echogenic (brighter because
there is more acoustic power to reflect back to the transducer).

Important term 2 “Posterior acoustical shadowing”

When ultrasound hits a dense object such as a gallstone and is completely reflected, a posterior
acoustical shadow is formed. The gallstone is bright and echogenic. Because no ultrasound
energy is left to go beyond the stone, an echo void is created, which appears as a wedge-shaped
dark area posterior to the dense object.

When is ultrasound most useful?

As a general rule, ultrasound is best at distinguishing the characteristic echo-free appearance
seen in fluid collections or cysts. It works best on thin patients and on body parts closest to the
skin. Ultrasound does not work well in the presence of gas or air or in larger patients.

IAN KINKOH 17
What are the safety considerations for ultrasound?
Ultrasound is the safest of all current imaging modalities. There is no magnetic field and no
radiation to be concerned about. No harmful effects have been proven when ultrasound is
performed at diagnostic frequencies.

What are 3D and 4D ultrasound?

Three-dimensional ultrasound uses the same principles as 2D ultrasound but adds a position-
sensing component to produce the effect of a 3D image. As with CT, 3D imaging is helpful to
examine contour. Currently, 3D ultrasound is used primarily in pregnancy ultrasound to provide
a snapshot of the fetus. The detail possible with 3D ultrasound is incredible, especially in the
delicate facial area, but also in the heart chambers and valves. Four-dimensional ultrasound adds
the fourth dimension of time. It is essentially a motion video of the three-dimensional fetus.
Diaphragm activity, limb movement, and cardiac motion can be seen clearly in real time

IMPORTANCE OF ULTRASOUND
Ultrasound enables the doctors to;
➢ confirm a pregnancy
➢ Monitor the evolution of the fetus
➢ diagnose the number of fetuses
➢ placenta position
➢ quantity of amniotic fluid
➢ state of the internal organs of the body

IAN KINKOH 18
 ➢ view the nature of blood vessels
➢ See the functioning of the heart (cardio.
TYPES OF ULTRASOUND PROCEDURES
* Endoscopy ultrasound
* Doppler ultrasound
* Colorado Doppler
* Duplex and tripled ultrasound
* Transvaginal ultrasound
ULTRASOUND EFFECT IN PREGNANCY.
No evidence is reported as far as biological effect of ultrasound on the fetus and mother is
concerned. Thus, it's a very safe technique.
The advantage ultrasound has over the other imaging techniques is that it is readily available,
cheap, and non-ionizing (not harmful to the body).

MAGNETIC RESONANT IMAGING (MRI)

Magnetic Resonance Imaging (MRI) is a technology that uses radio waves and a magnetic field
to provide detailed images of organs and tissues. The first magnetic resonance image was taken
in 1973 and the first MRI scanner for medical imaging was developed in 1977.

IAN KINKOH 19
IAN KINKOH 20
IAN KINKOH 21
IAN KINKOH 22
IAN KINKOH 23
IAN KINKOH 24
IAN KINKOH 25