Medical imaging using ionizing radiation: Optimization of dose and image quality in

fluoroscopya)
A. Kyle Jones, Stephen Balter, Phillip Rauch, and Louis K. Wagner

Citation: Medical Physics 41, 014301 (2014); doi: 10.1118/1.4835495

View online: http://dx.doi.org/10.1118/1.4835495
View Table of Contents: http://scitation.aip.org/content/aapm/journal/medphys/41/1?ver=pdfcov
Published by the American Association of Physicists in Medicine

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Medical imaging using ionizing radiation: Optimization of dose and image
quality in fluoroscopya)
A. Kyle Jonesb)
Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030

Stephen Balter
Departments of Radiology and Medicine, Columbia University, New York, New York 10032
Phillip Rauch
Retired-Henry Ford Health System, Detroit, Michigan 48202

Louis K. Wagner
Department of Diagnostic and Interventional Imaging, The University of Texas Medical School at Houston,
Houston, Texas 77030
(Received 29 August 2013; revised 4 November 2013; accepted for publication 11 November 2013;
published 9 December 2013)
The 2012 Summer School of the American Association of Physicists in Medicine (AAPM) focused
on optimization of the use of ionizing radiation in medical imaging. Day 2 of the Summer School
was devoted to fluoroscopy and interventional radiology and featured seven lectures. These lectures
have been distilled into a single review paper covering equipment specification and siting, equipment
acceptance testing and quality control, fluoroscope configuration, radiation effects, dose estimation
and measurement, and principles of flat panel computed tomography. This review focuses on modern
fluoroscopic equipment and is comprised in large part of information not found in textbooks on the
subject. While this review does discuss technical aspects of modern fluoroscopic equipment, it focuses
mainly on the clinical use and support of such equipment, from initial installation through estimation
of patient dose and management of radiation effects. This review will be of interest to those learning
about fluoroscopy, to those wishing to update their knowledge of modern fluoroscopic equipment, to
those wishing to deepen their knowledge of particular topics, such as flat panel computed tomography,
and to those who support fluoroscopic equipment in the clinic. © 2014 American Association of
Physicists in Medicine. [http://dx.doi.org/10.1118/1.4835495]

Key words: fluoroscopy, angiography, tissue effects, skin dose, flat panel computed tomography, cone
beam computed tomography

ACRONYMS, ABBREVIATIONS, AND TERMS blood vessels in the fluoroscopic

30-30-30 Rule An empirically derived rule, pro-
posed by Phil Rauch, to calcu-
late the appropriate IAKR to a
fluoroscopic image receptor. It is
intended to be used as a starting
point for setting the IAKR for
newly installed equipment. The
values should then be modified
according to the demands of the
imaging task, the noise tolerance
of the physician, and in response
to other considerations such as
the most commonly used FOV,
the pulse rate, the pixel size, and
the image receptor type.
3D roadmap A three dimensional version of a
roadmap. Rotational movement
of the C-arm will cause the 3D
image to rotate so that the pro-
jected 3D image is coincident
with the projected location of
ACQ (acquisition)
ADRC (Automatic Dose
Rate Control)
AEC (automatic exposure
control)
ALARA (as low as rea-
sonably achievable)
image.
Mode of operation of a fluoro-
scope during which images are
recorded for later review. Typ-
ically uses a higher image re-
ceptor dose per frame, and con-
sequently a higher patient dose,
than fluoroscopic imaging.
Technical mechanism by which
the output of the x-ray tube is
modulated during fluoroscopic
imaging to maintain a constant
output signal from the detector.
Technology used to automati-
cally adjust the image receptor
input exposure as variables in
the imaging protocol, geometric
setup, or x-ray beam path length
are changed during the proce-
dure.
An approach to radiation pro-
tection which advocates taking
all reasonable steps to lower the

014301-1 Med. Phys. 41 (1), January 2014 0094-2405/2014/41(1)/014301/26/$30.00 © 2014 Am. Assoc. Phys. Med. 014301-1
014301-2 Jones et al.: Optimization of dose and image quality in fluoroscopy
Angular sampling
a-Se (amorphous sele-
nium)
Beam hardening artifact
Bowtie filter
BSF (backscatter factor)
C-arm fluoroscope
CBCT (cone beam com-
puted tomography)
CCD (charge coupled de-
vice)
CINE (cineradiography)
CNR (contrast to noise
ratio)
Cone beam artifact
Medical Physics, Vol. 41, No. 1, January 2014
occupational dose to radiation
workers.
The angle between consecutive
measured projections during CT
acquisition.
Photoconductor utilized as the x-
ray conversion layer in a direct
capture type of FPD.
CT artifact caused by an in-
crease in average energy of the
x-ray beam as it passes through
the imaged object. Characterized
by reduced image intensity near
the center of the object imaged
or near highly attenuating struc-
tures, e.g., the skull.
Physical filter used to shape a
CT x-ray beam to the body part
being imaged and to account
for x-ray intensity differences
caused by the inverse square law.
The ratio of the skin or surface
exposure to the exposure in air
at the same location and for the
same x-ray beam quality.
A fluoroscope composed of an
x-ray tube and XRII or FPD
that are mechanically linked by
a C-shaped arm. C-arm fluoro-
scopes feature an isocenter, the
point through which the central
ray passes independent of gantry
orientation.
Computed tomography utilizing
a wide cone angle includes both
diagnostic CT with large detec-
tor array (e.g., 320 slice scan-
ner) and FPCT systems. Some-
times used interchangeably with
FPCT, however, FPCT is a sub-
set of CBCT.
A light sensor used in digital
television cameras.
Mode of operation of a fluoro-
scope during which images are
recorded at a high frame rate
for later review, often used dur-
ing cardiac catheterization. Typ-
ically uses a lower image recep-
tor dose per frame than ACQ, but
a higher frame rate (15–30 fps).
A measure used to assess image
quality. It is calculated from the
difference between the signal in
two regions of an image divided
by the background image noise.
CT artifact that occurs when us-
ing a large cone angle for CT
014301-2
projection acquisition. Charac-
terized by a decrease in reso-
lution along the z-axis as dis-
tance from the plane of rotation
(z = 0) increases.
CsI(Na) X-ray conversion layer that uses
a crystalline form of cesium io-
dide doped with sodium to pro-
duce light in the blue region of
the electromagnetict spectrum.
CsI(Tl) X-ray conversion layer that uses
a crystalline form of cesium io-
dide that is doped with thallium
to produce light in the green
region of the electromagnetic
spectrum.
CSV (comma separated Data record consisting of fields
value) separated by a comma.
CTDI phantoms Acrylic phantoms used to mea-
sure the computed tomography
dose index (CTDI). Typically 15
cm in length and either 16 cm
(head) or 32 cm (body) in di-
ameter. The phantoms have cav-
ities for inserting a pencil ion-
ization chamber, including one
in the center of the phantom and
four equally spaced around the
periphery of the phantom, 1 cm
below the phantom surface.
CTDI100 CT dosimetry quantity measured
using a 100 mm pencil ioniza-
tion chamber placed in a CTDI
phantom and a single rotation
of the x-ray source and can be
quoted as dose to air or dose to
the phantom.
CTDIw (weighted com- CT dosimetry quantity calcu-
puted tomography dose lated by summing 2/3 of the
index) CTDI100 measured at the periph-
ery of the phantom and 1/3 of the
CTDI100 measured in the center
of the phantom.
Del (detector element) Discrete region on a digital im-
age receptor from which an out-
put signal is derived.
Tissue effect Radiation effect that is charac-
terized by a severity that is de-
pendent on dose and a threshold
level below which no effect is
seen.
DICOM (Digital Imaging A standard for handling, storing,
and Communications in printing, and transmitting data in
Medicine) medical imaging.
Dp (dose per projection) The radiation dose delivered to
the image receptor per CT image
projection.
014301-3 Jones et al.: Optimization of dose and image quality in fluoroscopy
DQE (detective quantum
efficiency)
DSA (digital subtraction
angiography)
FDA (Food and Drug Ad-
ministration)
f-factor
FGI (fluoroscopically
guided interventions)
FOR PRESENTATION
FOR PROCESSING
FOV (field of view)
FPCT (flat panel com-
puted tomography)
FPD (flat panel detector)
fps (frames per second)
Medical Physics, Vol. 41, No. 1, January 2014
A measure of image quality
mathematically derived from
measurements of the MTF and
NPS.
Mode of operation of a fluoro-
scope during which a mask im-
age without contrast is acquired
and subtracted from subsequent
fill images acquired after injec-
tion of a contrast agent. Other-
wise similar to ACQ imaging.
United States Department of
Health and Human Services
agency responsible for protect-
ing and promoting public health.
A conversion factor that allows
the calculation of absorbed dose
from exposure.
Medical procedures, often
catheter-based, performed under
fluoroscopic imaging guidance.
Images to which image pro-
cessing (e.g., edge restoration
and harmonization) has been ap-
plied.
Images to which only detector
corrections (gain, offset, and bad
pixel) have been applied.
Used to describe either (1) the
size of the collimator opening at
the image receptor or (2) the full
field of view of the current elec-
tronic magnification mode being
used. In the second case, it refers
to the diagonal size of the field of
view.
Computed tomography imaging
performed with a device utiliz-
ing a FPD.
Large area image receptor that
uses an x-ray conversion layer
and a thin film transistor (TFT)
array to convert a low x-ray
photon fluence to electronic
charge. Indirect FPDs use a crys-
talline scintillator, most com-
monly CsI(Tl), to convert x-rays
to light and an array of photo-
diodes to convert light to elec-
tronic charge, which is stored on
the TFT array. Direct FPDs use
a photoconductor, most com-
monly a-Se, to directly con-
vert x-rays to electronic charge,
which is stored on the TFT array.
The number of unique image
frames presented to the viewer in
one second.
014301-3
GI fluoroscope The most basic fluoroscope, pri-
marily used for gastrointestinal
(GI) examinations. It consists of
an x-ray tube under the patient
table and an XRII or FPD above
the patient table.
HVL (half value layer) A measure of x-ray beam qual-
ity. It is the thickness of a ma-
terial such as aluminum or cop-
per that would reduce the in-
tensity of an x-ray beam by
50%.
HVS (human visual sys- The eyes and associated neural
tem) circuits responsible for process-
ing visual information.
IAK (input air kerma) Value of the air kerma at the en-
trance to the image receptor.
IAKR (input air kerma Value of the air kerma rate at the
rate) entrance to the image receptor.
IEC (International A nonprofit, nongovernmental
Electrotechnical Com- international standards organiza-
mission) tion.
IFU (instructions for use) Written instructions provided
by the manufacturer of imag-
ing equipment which detail the
proper procedures for operating
and controlling the equipment.
IR (interventional radiol- Subspecialty of radiology that
ogy) uses fluoroscopic guidance to di-
agnose and treat abnormalities
occurring in organs and blood
vessels of the body.
IRP (interventional refer- On C-arm fluoroscopes, a point
ence point) 15 cm towards the x-ray source
from isocenter.
Isocenter The point in space about which
a C-arm fluoroscope rotates. An
object placed at isocenter re-
mains in the center of the FOV
at any gantry angle.
Ka,i (incident air kerma) The air kerma incident on a pa-
tient’s skin. It does not include
contributions from backscatter.
Ka,r (reference air kerma) The cumulative air kerma at the
IRP.
kVp The value of the peak kilovolt-
age utilized to produce an x-ray
beam.
kVp modulation Modulation of kVp during CT
scanning to maintain a constant
Dp to the image receptor.
LIH (last image hold) Fluoroscope feature that dis-
plays the final fluoroscopic
frame on the viewing monitor
after the fluoroscopy pedal has
been released.
Limited angle scan CT scan using less than a 360◦
rotation
014301-4 Jones et al.: Optimization of dose and image quality in fluoroscopy
mA (milliampere)
Matrix
MIP (maximum intensity
projection)
ms (millisecond)
MTF (modulation trans-
fer function)
NEMA (National Electri-
cal Manufacturers Asso-
ciation)
NPS (noise power spec-
trum)
Osteoradionecrosis
PACS (picture archiving
and communication sys-
tem)
Pixel (picture element)
Pixel pitch
PKA (kerma area product)
pps (pulses per second)
PSD (peak skin dose)
QA (quality assurance)
RCE (relative contrast en-
hancement)
Medical Physics, Vol. 41, No. 1, January 2014
Unit of electric current. 1 mA
equals 10−3 ampere.
Array of numbers or pixels in
discrete rows and columns.
An image created by ray trac-
ing through a series of images
in a single anatomic plane (e.g.,
coronal) and assigning the max-
imum intensity encountered by
each ray to the pixel it intercepts
in the MIP.
Unit of time measurement. 1 ms
= 10−3 s.
A measure used to assess im-
age quality. It is a mathematical
function that describes contrast
transfer as a function of spatial
frequency.
Association of electrical and
medical imaging equipment
manufacturers in the United
States.
A measure of image quality that
describes the noise content of an
image as a function of spatial
frequency.
Necrosis of bone tissue resulting
from damage to the bone caused
by high absorbed doses of radia-
tion.
Technology used to store and
distribute digital medical im-
ages.
The smallest discrete spatial area
containing image signal inten-
sity information in a digital im-
age. A digital image is com-
posed of an array of pixels.
The distance between the centers
of two adjacent image pixels.
Product of air kerma and x-ray
field size, invariant along the
x-ray source to image receptor
axis.
The number of radiation pulses
produced by the fluoroscope
in 1 s.
The highest absorbed dose to
any area of a patient’s skin dur-
ing an FGI.
The systematic measurement,
comparison with a standard, and
monitoring of processes to mon-
itor performance and prevent un-
expected errors.
A technique used for quantifi-
cation of contrast enhancement
using relative differences in CT
014301-4
numbers measured in the same
locations in pre- and postcon-
trast CT scans.
RDSR (radiation dose A DICOM object that contains
structured report) information related to the pa-
tient, total dose metrics, and
dose metrics and fluoroscope
configuration for each irradia-
tion event during an FGI.
Roadmap An image of contrast filled ves-
sels which is made semitranspar-
ent and overlaid onto the live flu-
oroscopic image.
SC (secondary capture) A DICOM information object de-
finition. A secondary capture is a
“screenshot” of a digital image.
SFOV (scan field of view) The FOV at isocenter imaged
with CT
Shading/cupping artifact CT artifact caused by a combi-
nation of scattered radiation and
beam hardening and character-
ized by reduced image intensity
near the center of the imaged ob-
ject.
SID (source to image re- The distance between the x-ray
ceptor distance) source and input to the image re-
ceptor.
SNR (signal to noise ra- The magnitude of a signal di-
tio) vided by the magnitude of back-
ground noise.
SNRin (input signal to The SNR at the input to an image
noise ratio) receptor.
SNRout (output signal to The SNR at the output of an im-
noise ratio) age receptor.
Spectral filtration Filtration added (e.g., 0.1 mm
Cu) to the x-ray beam path for
the purpose of increasing beam
quality.
SPR (scatter-to-primary The ratio of the intensity of the
ratio) scattered radiation in an x-ray
beam divided by the intensity of
the primary radiation.
Stochastic effect Radiation effect marked by hav-
ing no threshold, a long la-
tent period, a likelihood of oc-
currence that increases with in-
creasing dose, and a severity that
is independent of dose.
TCM (tube current modu- Modulation of mA during CT
lation) scanning to maintain a constant
Dp to the detector.
Truncation artifact CT artifact that occurs when
imaging objects that exceed the
SFOV.
XRII (x-ray image inten- Vacuum bottle structure that
sifier) functions as a transducer to con-
vert a low x-ray photon fluence
to a high optical photon fluence.
014301-5 Jones et al.: Optimization of dose and image quality in fluoroscopy 014301-5

1. INTRODUCTION 2. In most cases, operators and support staff work in the

scattered radiation fields produced during the proce-
Fluoroscopic imaging supports a wide range of diagnos-
dure and are thus subjected to chronic exposure to
tic and image guided interventional medical procedures. Flu-
x-rays.
oroscopy per se is intended to visualize dynamic activities.
Most fluoroscopic systems also offer one or more fluoro-
2. FLUOROSCOPIC EQUIPMENT AND SITING
graphic (acquisition) modes for later review of images. Ac-
quisition (ACQ) includes single images (spot films) and se- 2.A. Modern fluoroscopic equipment
rial image sequences such as digital subtraction angiography
Most modern fluoroscopic systems use the same imaging
(DSA) and cineradiography (CINE). Modern fluoroscopic
channel for both fluoroscopy and ACQ. The x-ray beam pass-
imaging systems also provide fluoroscopic last-image-hold
ing through the patient is detected by an image receptor, ei-
(LIH) and retrospective storage of the most recent fluoroscopy
ther a vacuum x-ray image intensifier (XRII) or a solid-state
loop. These “reuse” modes provide review images without
device, most commonly a flat panel detector (FPD). Active
re-irradiating the patient. They are also of great value during
feedback from the image receptor to the generator modu-
physics image quality evaluations.
lates x-ray output in real time. Detected images are converted
There are two major differences between clinical fluoro-
into digital video signals which are then processed, displayed,
scopic procedures and most other imaging procedures:1
and possibly recorded. The active mode of system opera-
1. Only the dose rate of the equipment can be configured. tion is selected from a menu of clinical options and subop-
The total dose delivered to a patient during a procedure tions. The actual technical parameters are determined by a set
is determined by both the equipment and how it is used of configuration files associated with each operator selection
by the operator during the procedure. (Fig. 1). Default configuration file sets are preinstalled in new

F IG . 1. Example of some of the technical parameters associated with a procedure selection (organ program) on a modern fluoroscope.

Medical Physics, Vol. 41, No. 1, January 2014

014301-6 Jones et al.: Optimization of dose and image quality in fluoroscopy
equipment. These files are often modified to meet local pref-
erences during installation and system configuration.
Different clinical requirements are supported by changing
components such as the mechanical configuration, x-ray tube,
image receptor size, and image processor. Most fluoroscopes
are further adapted to specific clinical requirements by the
installation of task-specific software modules and configura-
tion files, such as the file shown in Fig. 1. The dosimetric
and imaging behavior of an individual system usually differs
from one clinical mode to another,2 and such differences are
often substantial. It is essentially impossible to fully test such
a system in a clinical setting. Medical physicists should eval-
uate a system using the expected clinical modes of use for
that specific system in their institution. Reference baseline
dosimetry and performance information for a range of recom-
mended uses is supplied by the manufacturers of International
Electrotechnical Commission (IEC)-compliant interventional
fluoroscopes.3 Scatter field isodose curves are also available.
This information is tabulated in the user manual or supple-
ments to the user manual.
2.B. Interventional fluoroscopic facility design
This discussion is limited to a sampling of some of the el-
ements of an interventional fluoroscopic facility relevant to
medical and health physics. The final design should represent
the consensus of all stakeholders and result in a workspace
that is as optimized as possible to meet the requirements
of staff safety, anticipated clinical requirements, and patient
safety.4, 5
Interventional fluoroscopes are commonly purchased as a
complete system that is configured to perform a specific range
of procedures, e.g., angiography, cardiology, or neuroradiol-
ogy. Most offerings include a base system and a series of op-
tions. Manufacturers may not offer all compatible options,
some of which may be of value to a facility. The medical
physicist should help the facility understand the proffered op-
tion list in the context of all available options. A large assort-
ment of additional imaging devices, workstations, network
terminals, etc. usually supplements the fluoroscopic system
package.4, 5
Fluoroscopic equipment vendors often provide generic sit-
ing plans in the context of intended clinical use for each
of their systems. Many of these are accessible on the ven-
dor’s web site. Additional siting plans can be obtained from
vendor sales personnel or from the project architect. These
are the starting point for developing the actual plan used to
construct the room. The final plan and specification should
include inputs and sign-offs by key entities such as the
equipment supplier, clinical staff, facility administration, and
radiation safety.
2.B.1. Radioprotective shielding
Radiation shielding for workers in the interventional lab-
oratory is more complex than that needed for a conventional
gastrointestinal (GI) fluoroscope.6, 7 Total reliance on personal
shielding such as protective garments, thyroid collars, and
Medical Physics, Vol. 41, No. 1, January 2014
014301-6
protective eyewear is usually adequate but seldom as low as
reasonably achievable (ALARA). Operators work from both
sides of the patient during an increasing fraction of proce-
dures. Face shields and table-mounted drapes should be sup-
plied for both sides of the table for such procedures. Several
support staff can be in the procedure room during a proce-
dure performing any one of a number of relevant tasks. Tasks
that do not require patient contact or hand-offs to the op-
erator should be accommodated in the control room when
feasible. Fixed or mobile radiation barriers should be sup-
plied for the protection of remaining in-room staff where
practicable.
2.B.2. Access door designs
Door designs, both control-procedure and hall-procedure,
require specific attention. In general, patient safety can be
compromised if any interventional laboratory doors are inter-
locked to block radiation production when they are opened.
However, it must be understood that doors, and particularly
corridor doors, should be closed as much of the time as pos-
sible. Instead, separate x-ray disable controls should be used
to block radiation production unless a procedure is actually in
progress. Many interventional fluoroscopes provide this func-
tion via a dedicated switch. A wall-mounted control can eas-
ily be provided for any other room. Doors that might remain
open during procedures, e.g., control-procedure, should not
provide a line of sight from the isocenter to any substantially
occupied area. Individuals entering the control room should
not have to pass through an unshielded area on their way from
the corridor to the control room. These requirements can be
accommodated by appropriately locating the position of the
door in the barrier and configuring the direction of the door
swing (Fig. 2).
2.C. Fluoroscope evaluation and testing
The evaluation of a fluoroscope, and for that matter any
type of imaging equipment, can be divided into three main
phases: acceptance, commissioning, and acceptability.8 As
outlined below, the nature of a medical physics evaluation
differs in each phase. National Electrical Manufacturers As-
sociation (NEMA) Standard XR-27, first issued in 2012 and
scheduled to be implemented by 2015,9 is expected to facil-
itate all phases of testing of interventional fluoroscopes. Key
elements of XR-27 are outlined in Table I.
2.C.1. Acceptance testing
Acceptance testing is the initial complete and detailed eval-
uation of a new system, including the x-ray generator, image
receptor, image processing and handling chain, and other ma-
jor components; or the reevaluation of all or part of an exist-
ing system after major repairs or upgrades. Acceptance test-
ing verifies that the system meets regulatory requirements,
its manufacturer’s specifications, and additional contractual
requirements negotiated between the facility and vendor. A
014301-7 Jones et al.: Optimization of dose and image quality in fluoroscopy
F IG . 2. Good and bad design for fluoroscopic procedure suites. The only
entry to the control room in version (1) is via the patient entry door (P) and the
control room door (C). Any staff entering or leaving the control room while
a procedure is in progress may be irradiated. A control room staff door (S)
is added in version (2). Individuals passing to or from the control desk might
be irradiated if the control room door (C) is open. In addition, individuals
might be tempted to take a short-cut to the control room via the patient entry
door (P). By moving the control room staff door (S) to the location shown in
version (3), the area around the staff door (S) is completely shielded by the
control-procedure room barrier. In addition, by locating (S) close to (P), it is
unlikely that an individual going to the control room will pass through the
procedure room.
radiation protection survey is always part of initial accep-
tance testing and may be needed following major repairs.
Acceptance testing also provides a baseline for periodic ac-
ceptability testing, often referred to as “QA.” Acceptance test-
ing should be comprehensive and based on the factory de-
faults for the specific system’s intended use. However, not
all of the items included in an acceptance test, e.g., half-
value layer (HVL) for systems where the filters are com-
pletely enclosed in the x-ray tube housing, require routine
acceptability testing. Table II summarizes a typical set of ac-
ceptance tests that might be performed on an interventional
fluoroscope by a medical physicist. Testing protocols can be
found elsewhere. Professional judgment must be applied to
refine this list to comply with local regulatory and facility
requirements.
Medical Physics, Vol. 41, No. 1, January 2014
014301-7
2.C.2. Commissioning
Commissioning is the verification that a system is prop-
erly configured to meet the facility’s clinical requirements
while maintaining regulatory compliance and acceptable per-
formance goals. New systems are typically delivered with a
set of “factory default” configuration protocols. These enable
use of the system to perform a wide variety of generic clini-
cal procedures. Some or all factory defaults may not meet the
clinical needs of the facility in which the fluoroscopic imag-
ing system is installed. Over the first few months of clinical
use, the configurations supporting those procedures which are
actually performed are often adapted to meet the facility’s
clinical requirements by a combination of facility and ven-
dor personnel. Adaptation can markedly affect both radiation
delivery and image characteristics. It is prudent to carefully
evaluate the performance of adapted settings after clinical
configuration is complete. Equipment use may change over
time. Commissioning testing should include re-measurement
of those factors that were modified by the commissioning pro-
cess. Appropriate commissioning tests should be repeated af-
ter significant clinical reconfigurations.
2.C.3. Acceptability testing
Acceptability testing provides periodic assurance that an
apparently stable system remains legally and clinically suit-
able for continued use. Recommendations for acceptability
testing of all forms of imaging equipment, including fluoro-
scopes, are available in AAPM Reports10–15 and are reviewed
in European Commission report RP-162.8
An apparently unstable system should be reported to fa-
cility management by its operators in a timely manner and
then subjected to additional testing. Test results may indicate
the need for routine or urgent maintenance. Depending on the
findings, the system may have to be taken out of service or
have its clinical usage restricted until maintenance is com-
plete. A system might have to be taken out of service per-
manently if critical repairs are impossible, e.g., parts are no
longer available.
As noted above, routine acceptability tests are a subset
of the more comprehensive list of acceptance tests shown in
Table II. Performance of acceptability testing over the range
of actual clinical use is essential. However, resources should
not be expended on evaluating unused options, e.g., pediatric
performance of fluoroscopy equipment only used for adults,
or on items that are unlikely to change in a stable system, e.g.,
remapping the scattered radiation field in a system with intact
protective drapes. The medical physicist should exercise pro-
fessional judgment and perform additional testing based on
clinical reports and the findings of the baseline tests.
2.D. Summary
The evaluation of fluoroscopic imaging systems can be di-
vided into three main phases: acceptance testing, commis-
sioning, and acceptability testing. Medical physics involve-
ment at each step is crucial, as deficiencies at any step can
render the system unsuitable for clinical use. Standards and
014301-8 Jones et al.: Optimization of dose and image quality in fluoroscopy 014301-8

TABLE I. Elements in NEMA Standard XR-27—X-ray equipment for interventional procedures: User Quality Control Mode (Ref. 9).

Element Rationale

Manual control of: Supports testing for:

kV
mA
Pulse width
Spectral filtration
Focal spot size
Export of configuration file sets in a suitable
format, e.g., comma-separated value (CSV)
Export of FOR PROCESSING and FOR
PRESENTATION images in nonproprietary
formats that include numerical pixel maps
Access to Radiation Dose Structured
Reports (RDSR)
Calibration inputs for fields in the RDSR
Half-value layer
Dose reproducibility
mA linearity
kVp, mA, pulse width accuracy
Ka,r and PKA accuracy, x-ray tube output measurement
This will include an audit trail to identify the individual/entity that changed the file
An off-line tool is to be provided that automates comparison between the current configuration and the
factory default set of configuration files
This is expected to facilitate the development of physical phantoms that can be imaged and digitally
analyzed for QA purposes, e.g., SNR, CNR, MTF
Provides a portal for downloading RDSRs in the absence of necessary network resources
The RDSR requires correction factors in each report. These factors are applied to machine-reported dose
metrics to arrive at final values for these metrics
Measurement protocol is currently under development by AAPM TG-190

TABLE II. Typical fluoroscope acceptance testing items.

Phase Aspects evaluated

Delivery Installed system matches the purchasing documents

Documentation
Initial configuration
Radiation protection survey
Functional and safety survey
Monitor quality
Image receptor uniformity
Collimator
All accessories are present
All options, including hardware and software, are present and installed correctly
Essential user instructions as hard-copy
Manufacturer’s complete accompanying documents, including standard dosimetry, in electronic or hard-copy format
Complete set of initial configuration settings, in human readable form and as system backup media
Complete set of “as installed” drawings in electronic or hard-copy format
System has been configured and calibrated according to factory standard settings
Most common intended use(s) identified
Patient population identified
Initial determination that the factory standard settings are clinically acceptable
Approved radiation protection design is available
All required and specified radiation protection accessories are present and installed correctly
Radiation protection survey performed and documented according to local requirements, including regulatory and
facility
All mechanical functions of the system are acceptable
All safety interlocks are functional
All switches, both hardware and virtual, and indicators are functional.
Grid is removable if so designed
Five-minute fluoroscopic timer functional
All “x-ray active” warning lights functional
X-ray disable function performs as described in the system user manual
Electrical safety survey completed and system passes
Emergency power-off functional
Backup power functional
Network interfaces, including data and images, are functional.
All x-ray image monitors in procedure room and control room have acceptable performance
All non-x-ray displays have acceptable performance
Image receptors and grids are acceptably uniform in response and free from clinically important artifacts
Relation of visualized to actual x-ray field meets regulatory requirements
Collimator size tracks with changes in field of view (FOV) and source-to-image distance (SID)
Minimum x-ray field size meets regulatory requirements
Auxiliary collimator elements function in accordance with the instructions for use (IFU)
SID indicator is acceptably accurate

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TABLE II. (Continued.)

Phase Aspects evaluated

HVL and kVp
Radiation output
Integrated radiation dose displays
Low contrast detectability
High contrast detectability
HVL meets or exceeds regulatory minimums under all conditions
kVp accuracy meets or exceeds manufacturer’s specifications and/or regulatory requirements
Note: This testing may require assistance from the installers to set appropriate x-ray generator parameters.
Tested for the most common anticipated clinical examination(s)
Testing includes imaging modes and submodes associated with identified clinical procedures
Testing includes all available FOVs of the system
Pediatric-specific testing included, if pediatric patients will be examined or treated using the fluoroscope under
evaluation
Testing for each mode covers the full range of patient thickness, including those that are expected to drive the system to
maximum output
Testing includes all modes of operation, including fluoroscopy, ACQ, DSA, and CINE
Effects of SID on table-top output.
Caution: Consider the characteristics of the external radiation detector(s) used for these measurements,
especially with beams filtered by copper, and the influence of the detector(s) on the output of the fluoroscope.
System displays reference air kerma and reference air kerma rate
Use AAPM TG-190 protocol when it is available
Accuracy meets or exceeds IEC, FDA, and manufacturer’s standards.
Measured correction factor installed in the system for use with the RDSR, when this function is available
Typically performed for all modes and FOVs using either constant physical contrast tools, e.g., different size holes in a
single test plate, or with a contrast-size phantom
Consider also using iodine or iodine-simulating, e.g., tin, contrast targets
Visual analysis of resulting images, including dynamic analysis if this corresponds to clinical use. Replay functions
should be used to analyze images without the need to continuously irradiate the test object
Tools and geometry per regulatory and/or local requirements
Typically performed for all modes and FOVs using a lead bar pattern and a suitable attenuator
Also consider using clinical guide wires and stents or other devices
The system should be set to a clinically relevant table height and SID
Test object placed near the location of the patient’s input surface to include the influence of focal spot size and
magnification on high contrast detectability
Additional testing at maximum SID can be helpful
Bars should be rotated 90◦ for a subset of the tests to gain an impression of focal spot asymmetry and other effects such
as video bandwidth
Images evaluated visually under dynamic conditions. Secondary magnification of the images may be used for this
purpose.

guidelines exist, both for specific tests and for overall evalu-
ation of fluoroscopic imaging systems. The medical physicist
must also exercise professional judgment in evaluating imag-
ing equipment, adapting testing algorithms according to both
equipment design and use.
3. CONFIGURING FLUOROSCOPIC EQUIPMENT
Commissioning a fluoroscope can be a daunting task con-
sidering the number of potential combinations of technical
factors and operational modifiers available on modern sys-
tems. A working knowledge of modern fluoroscopic equip-
ment and understanding a few basic principles makes the task
more manageable. The medical physicist must understand key
concepts including differences between FPD and XRII and
the behavior of fluoroscopes when changes are made to the
field of view or frame rate.
3.A. Differences between flat panel image receptors
and x-ray image intensifiers
The migration to FPD has resulted in real benefits to fluo-
roscope operators, including more flexibility in positioning of
the fluoroscope, elimination of common image artifacts, and
the introduction of advanced technologies including flat panel
computed tomography (FPCT) and 3D roadmapping that au-
tomatically tracks the position of the imager. However, FPDs
are inferior to XRIIs in one particular aspect—image noise at
low input air kerma rates (IAKR). XRIIs and many FPDs use
the same x-ray conversion layer made of cesium iodide, doped
either with sodium for XRIIs [CsI(Na)] or with thallium for
FPDs [CsI(Tl)] (Although this discussion focuses on the “in-
direct” type of FPD (CsI/a-Si TFT array), it also applies to
the “direct” type of FPD (a-Se/a-Si TFT array).). The main
effect of the dopant is to shift the spectrum of the light emit-
ted by the phosphor and it is not present in sufficient concen-
tration to substantially affect the x-ray attenuation properties
of the conversion layer. Therefore, one might expect that the

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014301-10 Jones et al.: Optimization of dose and image quality in fluoroscopy 014301-10

DQE = [SNRout /SNRin ]2 for a FPD and an XRII would be

similar. However, the DQE of a FPD drops precipitously as
the IAKR is reduced to fluoroscopic levels, whereas the DQE
of an XRII remains relatively constant. The difference lies in
the fact that the XRII is a very high gain system, increasing
the number of secondary information carriers by a factor of
approximately 5000, while the FPD suffers from high levels
of additive noise, mainly electronic noise from the readout
and sampling of the detector. This places a dose “floor” on
the input air kerma (IAK) per frame necessary when using
a FPD for low IAK per frame applications, including fluoro-
scopic imaging and FPCT. This floor is in the range of 20–50
nGy/pulse.16–18

3.B. Pulsed versus continuous fluoroscopy

A shift to pulsed fluoroscopy that began 15 years ago is
now almost complete in interventional and cardiac labs. How-
ever, many users of fluoroscopy outside these areas continue
to use continuous fluoroscopy, which is inferior to pulsed flu-
oroscopy in terms of both radiation dose (to both the patient
and the operator) and image quality (Fig. 3).

3.C. Operational logic of modern fluoroscopes

Modern fluoroscopic equipment, and particularly equip-
ment used for fluoroscopically guided interventions (FGI),
operates under the direction of complex algorithms that con-
trol technical factors including kVp, mA, pulse width, and
in some cases added filtration to maintain a constant pre-
set detector output signal. The detector output signal is sam-
pled within a predefined measurement region on the detector.
Although the system operates to maintain a target detector
output signal, it is common to describe the mechanism as “Au-
tomatic Dose Rate Control” (ADRC). In some circumstances
the algorithm will also dynamically modify the value of the
target signal being used to achieve the proper imaging condi-
tions. The report of AAPM Task Group 125 (Refs. 19 and 20)
has provided a wealth of information on the operational logic
of modern fluoroscopes, and in particular on the function of
F IG . 3. Comparison of continuous and pulsed fluoroscopy. (a) Time se-
ADRC.
quences showing tube current (mA) during one second of fluoroscopy. (a.1)
Continuous fluoroscopy—radiation production and mA are continuous. (a.2)
3.D. Fluoroscopic input air kerma rates to the image Pulsed fluoroscopy—for a pulse rate of 30 pps, the mA per image frame is
receptor increased so that each image is produced with the same IAK used for each
frame of continuous fluoroscopy. (a.3) Pulsed fluoroscopy—for a pulse rate
3.D.1. XRII of 15 pps, the mA per image frame is increased over that used at 30 pps to
compensate for the increased perception of image noise as fewer images are
Setting the appropriate fluoroscopic IAKR to the image integrated by the human visual system when the pulse rate is decreased. This
receptor is perhaps the most challenging aspect of configur- phenomenon is described in detail in Sec. 3.D.3. (b) Patient dose rate for
ing a fluoroscopic imaging protocol. The FOV, fluoroscopic pulsed fluoroscopy at a rate of 30 pps is not changed compared to continuous
fluoroscopy, while patient dose rate for pulsed fluoroscopy at a rate of 15 pps
pulse rate, ADRC parameters, and image receptor technology,
is decreased compared to 30 pps. However, a 50% reduction is not achieved as
along with the imaging task and patient, all influence the se- the IAK per pulse was increased to maintain a constant perception of image
lection of the IAKR. Phillip Rauch has distilled much of this noise. (c) Fluoroscopic LIH images of a rotating disk. Edge blur is present
into his simple yet elegant “30-30-30 Rule,”21 which states: when an object moves a large distance during the frame integration time.
“For a nominal XRII FOV of 30 cm and a fluoroscopic rate (Right) Continuous fluoroscopy with frame integration time equal to 33.3 ms
produces a blurred image of moving objects. (Left) Pulsed fluoroscopy with
of 30 image frames per second, set the entrance exposure rate
a much shorter frame integration time (i.e., x-ray pulse width) of 8 ms pro-
to the image receptor to 30 μR/sec (262.8 nGy/sec).” duces a sharper image. Contrast is also improved, as seen in the images of
Rauch empirically derived this rule based on 30 years of the black dots at the edges of the rotating disks. This figure was previously
experience with setting the IAKR on XRIIs and qualitatively published in AAPM Report 125.

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014301-11 Jones et al.: Optimization of dose and image quality in fluoroscopy
monitoring the subsequent imaging performance and the sat-
isfaction of physicians performing different procedures using
the equipment. The intended use of Rauch’s 30-30-30 Rule
is as a starting point for setting the IAKR for newly installed
fluoroscopic equipment. The values should then be modified
according to the demands of the imaging task, the noise toler-
ance of the physician, and in response to other considerations
such as the most commonly used FOV, the pulse rate, the pixel
size, and the image receptor type as described below. As writ-
ten, the 30-30-30 Rule applies to an XRII with a pixel matrix
size of 1024 × 1024, often referred to as a “1k” matrix, typical
of a charge-coupled device (CCD) camera. This pixel matrix
divides a 30 cm FOV into “pixels” 293 μm on a side. If a
minimum of 0.2 mm Cu spectral beam filtration is used, the
IAKR can be doubled.22 The doubling of the IAKR is used to
compensate for the loss of CNR associated with x-ray beam
hardening, a consequence of shifting the average energy of
the x-ray spectrum beyond the k-edge of the CsI conversion
layer. The exact change in IAKR that is necessary depends
on the procedure being performed, the organ program config-
uration settings, and the noise tolerance of the operator. The
30-30-30 Rule is not intended to allow exact determination of
the IAKR but can be extremely useful in calculating an IAKR
that is reasonable and acceptable with regard to the tradeoff
between image noise and patient dose. It should be noted that
the stated entrance exposure rate of 30 μR/s (262.8 nGy/s) is
after the antiscatter grid. When measuring the IAKR, either
the antiscatter grid should be removed or a “grid factor” (i.e.,
reciprocal of the primary transmission of the antiscatter grid)
applied to the measured IAKR to determine the true IAKR to
the detector. Manufacturers often publish grid factors in their
service manuals to aid service engineers when calibrating flu-
oroscopes.
3.D.2. Flat panel image receptors
Rauch’s 30-30-30 rule was derived for XRII imaging sys-
tems using CsI(Na) conversion layers but it can be adapted
to estimate the IAKR needed for FPD fluoroscopic imaging
systems using CsI(Tl) or a-Se (Ref. 88) conversion layers. If
the effects of electronic noise are ignored for the moment, de-
livering the same photon flux to equivalent size pixels in the
XRII and in the FPD will achieve similar SNRout 2 . For a fluo-
roscopic image rate of 30 frames per second (fps) and a pixel
matrix of 1024 × 1024, we must determine the FPD IAKR
that will deliver equivalent SNRout 2 as that for an XRII hav-
ing the same pixel pitch as the FPD. If we then deliver this
same IAKR to an XRII and to an FPD, each having the same
pixel pitch and 10242 pixel matrix size, the SNRout 2 should
be equivalent and thus we have arrived at the equivalent FPD
IAKR.
An FPD with a pixel pitch of 0.154 mm and a FOV of
22 cm (diagonal measurement) will have a pixel matrix of
10242 . Because the XRII/CCD always has a pixel matrix of
10242 , we simply have to determine the input diameter of the
XRII that has the same 0.154 mm pixel pitch as that for the
FPD. This value is the product of the matrix dimension and
the pixel pitch:
Medical Physics, Vol. 41, No. 1, January 2014
014301-11
1024 pixels × 0.154 mm/pixel
= 15.8 cm. (1)
10 mm/cm
To achieve the same SNRout 2 as that for the 30 cm FOV,
an XRII operating at a 15.8 cm FOV would require (30/15.8)2
= 3.6 times greater IAKR, or 3.6 × 262.8 nGy/s = 946 nGy/s
(31.5 nGy/pulse). This value is therefore the IAKR that would
be required for a FPD operating at a pixel pitch of 0.154 mm
and a 10242 pixel matrix. Because we ignored the effects of
electronic noise in deriving this value of IAKR, the reality is
that the image noise would be slightly higher for the FPD as
compared to an XRII operating at the same pixel pitch, matrix
size and IAKR. Thus, one must consider the dose “floor” of
FPD when setting the IAKR, particularly when using high
fluoroscopic image rates, as discussed in Sec. 3.D.3.
3.D.3. IAKR changes with fluoroscopic image rate
The fluoroscopic image rate also influences the setting of
the IAKR to the image receptor. The human visual system
(HVS) has a finite integration time, and multiple fluoroscopic
images are integrated during one visual cycle. Integration in
the HVS occurs because whenever an image is projected onto
the retina, the photoreceptor stimulus from that image will
take approximately 200 ms to fade away completely.23 When
two or more images, each with a different random noise dis-
tribution, are presented within the 200 ms time frame, both
the image signal is reinforced and the image noise is reduced.
At high fluoroscopic image rates more fluoroscopic images
are integrated by the HVS compared to low image rates. As
the image rate is reduced, fewer frames are integrated, and
the perceived image noise increases. Dr. Richard Aufrichtig
studied this phenomenon and published an experimentally
measured empirical relationship that can be used to calculate
the necessary IAKR for fluoroscopic image rates less than
30 pps.24 The following expression can be used to scale the
IAKR for different fluoroscopic image rates, such that the vi-
sual impression of image noise remains relatively constant:

fpsold
IAKRnew = IAKRold × , (2)
fpsnew
where fps (frames per second) is the fluoroscopic image rate.
As can be seen from this relationship, a halving of the image
rate would not be expected to result in a halving
√ of the IAKR,
but instead a reduction by a factor of 1/ 2 if the perception
of image noise is to remain constant. The same logic does not
apply to all frame rates. Because any single image is retained
for only 200 ms (1/5 s), the only integration that occurs at
frame rates of 5 fps or less is that between the previous fill
frame and the current fill frame.89 Therefore, Eq. (1) should
be used only for frame rates of 5 fps or greater, and the re-
quired IAKR calculated for 5 fps should be used for frame
rates less than 5 fps.
In practice, only one manufacturer configures their default
imaging protocols to follow the Aufrichtig scale,25 and no
manufacturers configure their systems to use the Aufrichtig
scale when an operator uses the tableside controls to change
014301-12 Jones et al.: Optimization of dose and image quality in fluoroscopy 014301-12

the fluoroscopic image rate. The responsibility for making
these changes in the system configuration in order to main-
tain a constant perception of image noise as the frame rate is
changed therefore falls on the medical physicist.
3.D.4. IAKR changes with FOV
XRIIs use a CCD camera with a fixed matrix size but can
electronically vary the size of the input FOV. As a result, the
sampling pitch or “pixel size” at the input screen varies in pro-
portion to the diameter of the FOV. To maintain the same out-
put SNRout 2 when the FOV diameter is decreased (i.e., “Mag
Mode”), the IAKR must be increased inversely proportional
to the change in input screen area (Fig. 4). This change also
exactly compensates for the reduction of image brightness
caused by the reduction in minification gain as the image is
electronically magnified. FPDs have a fixed detector element
(del) size and therefore a fixed sampling pitch. However, the
pixel matrix size changes with the FOV, generally becoming
smaller as the FOV decreases. Because the pixel pitch remains
constant, there is no physical requirement to vary the FPD
IAKR as the FOV is changed. An exception to this principle
occurs whenever dels are binned, which is common for larger
(>31 cm) FOVs. In these cases the matrix size is reduced by a
factor equal to the reciprocal of the number of dels combined
into one image pixel. To achieve the same SNRout 2 , the larger
pixels that result from del binning require a lower IAKR, by
a factor of the reciprocal of the number of dels combined.
Although there is no physical basis for changing the IAKR
for a FPD when the FOV is changed, except in the case where
dels are binned, most manufacturers vary the IAKR inversely
proportional to the diagonal of the FOV (Fig. 4). Manufac-
turers use this strategy because they argue that the “percep-
tion” of image noise increases with magnification due to in-
creased visual acuity.26 Manufacturers may also adjust the
visual presentation of the image when the FOV is changed
by applying image processing, including harmonization, edge
enhancement, and noise reduction techniques to compensate
for the higher additive noise levels of flat panel image recep-
tors. When configuring a fluoroscopy imaging protocol, one
typically sets the IAKR for a specific baseline FOV (e.g., 1024
× 1024 matrix size, 22 cm diagonal), and the fluoroscopic
system adjusts the IAKR as the FOV is changed according to
the installed configuration files.
3.D.5. An example
For the FPD with the specifications described in Table III,
calculate the desired IAKR when the imager is operated in the
32 cm FOV at a fluoroscopic image rate of 15 fps.
First, determine the IAKR for the FOV corresponding to a
10242 matrix with an image rate of 30 fps. From Table III, the
22 cm FOV with 0.154 mm pixel pitch is selected. The cal-
culation of IAKR for this FOV and a fluoroscopic image rate
of 30 fps was performed in Sec. 3.D.2 and it was determined
that the required IAKR was 946 nGy/s (31.5 nGy/pulse).
Next, the IAKR is adjusted for the change in FOV. From
Table III, the vendor algorithm will automatically adjust the
relative IAKR from 100 to 71 (i.e., reduction of 0.71) when
the FOV is changed from 22 to 32 cm. Thus we must multiply
946 × 0.71 = 672 nGy/s (22.4 nGy/pulse).
Finally the Aufrichtig scale24 is applied to adjust the IAKR
for the change in image rate:

30 fps
IAKR15 fps = 22.4 nGy/pulse ×
15 fps
= 31.7 nGy/pulse or 475.5 nGy/s. (3)
The net result is a 50% reduction in IAKR from 946 to
475.5 nGy/s even though the dose per pulse remains nearly
constant.
As stated earlier, if the protocol is configured to include
at least 0.2 mm of copper filtration during fluoroscopy, the
IAKR can be increased up to a limit of double the calculated
value in order to achieve additional noise reduction.22 Such
increase should only be made, however, if the level of im-
age noise interferes with the perception of the required image
detail.
Maintaining the FOV at 32 cm and further reducing the flu-
oroscopic image rate to 7.5 fps would result in the following

TABLE III. Flat panel detector specifications.

FOV Pixel pitch Matrix Manufacturer’s specified

(cm)a (mm) (pixels) relative IAKR

48 0.308 960 × 1240 50

42 0.308 960 × 960 50
32 0.154 1440 × 1440 71
22 0.154 1024 × 1024 100
F IG . 4. Changes in IAKR as a function of FOV for two fluoroscopes us- 16 0.154 720 × 720 142
ing different image receptors, one an XRII (solid line) and the other a FPD 11 0.154 512 × 512 200
(dashed line). Both fluoroscopes were set to use 45 nGy/pulse at their respec-
tive baseline FOVs (17 cm for the XRII, 22 cm for the FPD). a
Diagonal dimension.

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014301-13 Jones et al.: Optimization of dose and image quality in fluoroscopy
changes to the IAKR:
 frame rate override settings. For single or serial acquisition,
15 fps
IAKR7.5 fps = 31.7 nGy/pulse ×
7.5 fps
= 44.8 nGy/pulse or 336.2 nGy/s.
In practice, only certain discrete values of IAKR are avail-
able on the fluoroscope and the closest available setting must
be selected. Also, the spacing between available values may
be such that it is impossible to precisely implement the
Aufrichtig scale.
3.E. Acquisition input air kerma to the image receptor
Single frame and serial image runs including digital acqui-
sition (ACQ), digital subtraction angiography (DSA), and cin-
eradiography (CINE) are an integral part of FGI procedures.
Because ACQ and DSA image runs are typically acquired at
frame rates less than 5 fps and individual frames are archived
or selected for interpretation, each frame must be produced
with sufficient IAK to provide acceptable image noise. There-
fore, the requirements for image noise are similar to that for
any digital radiographic acquisition. The image subtraction
inherent to DSA increases the noise in the final subtracted
image, and DSA is often configured to use a higher IAK per
frame than ACQ to compensate in part or in full for the addi-
tional noise. The IAK per frame used for CINE will depend on
the procedure, the frame rate, and the preferences of the per-
forming physician. Because most CINE runs are performed at
frame rates greater than or equal to 15 fps, some perceptual
integration of the frame noise does occur. Table IV provides
general guidelines for setting the appropriate acquisition IAK
per frame as a multiple of the fluoroscopic IAK per frame at
the same FOV and matrix size and, for CINE, at the same
frame rate.
3.F. Summary
Fluoroscopic imaging systems can be configured and the
IAKR for different types of fluoroscopes can be standardized
by using Rauch’s 30-30-30 Rule. Careful consideration must
also be given to properly adjusting the IAKR to the detector
as operational parameters are changed. The Aufrichtig scale
should be followed when configuring protocols with different
TABLE IV. Guidelines for setting the acquisition input air kerma per frame
to the image receptor.
Multiplier of the fluoroscopic
IAKa per frame for the same
Acquisition mode FOV and matrix size
Single 20–60
ACQ 40–60
DSA 50–80
CINE 3–8
a
IAK = input air kerma.
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014301-13
fluoroscopic image rates and, if possible, applied to tableside
there is generally a range of values of IAK per frame that
are used in practice, with specific settings depending on the
(4) procedure type and operator preferences.
4. ESTIMATING PEAK SKIN DOSE IN
FLUOROSCOPY
Estimating the peak skin dose (PSD) resulting from an FGI
is a multistep process. First, information related to radiation
dose must be gathered and interpreted. Second, the peak inci-
dent air kerma (Ka,i ) must be calculated based on the gathered
information. Third, correction factors must be applied to the
peak Ka,i to arrive at an estimate for the PSD. These steps are
discussed in more detail in this section.
4.A. Sources of information on radiation dose
There are many sources where information regarding ra-
diation dose related to FGI can be found. Images that are
archived during the procedure have associated DICOM head-
ers, and these headers contain information that can be used
to estimate the radiation dose to the patient from the proce-
dure. The DICOM standard27 can be consulted for informa-
tion regarding interpretation of the DICOM header, as can
DICOM conformance statements from equipment manufac-
turers. Beginning about 10 years ago, certain manufacturers
began creating proprietary dose reports containing informa-
tion related to individual digital acquisition runs and con-
taining total dose metrics for the procedure. Recently, man-
ufacturers have begun implementing the DICOM Radiation
Dose Structured Report (RDSR),28 which includes detailed
radiation dose information for each pedal activation during a
procedure. However, legacy systems may never support the
RDSR.
The accuracy of information sources must be verified, in-
cluding verifying compliance with the DICOM standard. This
may require the medical physicist to perform measurements
to confirm the accuracy of certain quantities. Contingency
plans may be needed for recording certain data that are not
available, or not accurate, in available dose information. The
methods used to collect dose information will vary based on
the options available on the fluoroscope. RDSRs can be trans-
mitted to DICOM network nodes, while proprietary dose re-
ports may have to be printed or archived as secondary capture
(SC) images on PACS.
Current efforts within the International Electrotechnical
Commission (IEC) and DICOM seek to standardize radia-
tion dose reporting and integrate comprehensive information
related to radiation dose, including technical factors, patient
models used to estimate dose, and geometry information into
a single report.
4.B. Estimating the peak incident air kerma
The most important step in estimating the PSD is arriv-
ing at a reasonable estimate of the peak Ka,i . This task can
014301-14 Jones et al.: Optimization of dose and image quality in fluoroscopy
range from simple, if dose reports or other information is pro-
vided by the fluoroscopic imaging system, to complex if little
or no dose information is available. Several scenarios can be
considered, including the availability of an RDSR or propri-
etary dose report, the availability of only DICOM headers, the
availability of only machine-reported dose metrics (reference
air kerma [Ka,r ] or kerma area product [PKA ]), or the availabil-
ity of only images and no associated dose information. These
scenarios are discussed in detail in two papers by Jones and
Pasciak,29, 30 and will not be addressed here.
Another important consideration is how the dose informa-
tion will be treated—piecemeal or wholesale. In a piecemeal
treatment, each digital acquisition series, and perhaps even
each fluoroscopic series if working from an RDSR, can be
considered separately. This is feasible when using computer
algorithms or spreadsheets to perform detailed dose recon-
structions. Wholesale treatment of the total Ka,r is simpler,
but perhaps less accurate, than piecemeal treatment.
If the Ka,r is known, the Ka,i can be calculated by apply-
ing two corrections. The first is an inverse square law cor-
rection using the known location of the interventional refer-
ence point (IRP),3 which can be found in the detailed doc-
umentation provided with a fluoroscope, and the distance
from the x-ray source to the patient. This information may
be found in the DICOM header, in an RDSR, or can be mea-
sured and recorded by a technologist involved with the proce-
dure. It is critically important that the accuracy of the infor-
mation used be verified. For example, one manufacturer in-
cludes the position of the patient support relative to isocenter
in the RDSR, but includes the calibrated measurement loca-
tion (15 cm above the patient support by default) in the “Dis-
tance Source to Patient” field in the DICOM header. The sec-
ond correction is for attenuation of the x-ray beam by the pa-
tient support and pad, if used. This factor should be measured
by the medical physicist at acceptance testing or after the in-
stallation of a new pad. A broad-beam geometry and clinical
beam quality should be used for the measurement. Typical
values range from 0.8 for thick viscoelastic pads to 0.9 for
half-thickness pads29–31 used in catheterization labs; however,
off-brand pads may attenuate the beam more.
4.C. Calculating the peak skin dose
To estimate the PSD from the Ka,i , two corrections must
be applied: the backscatter factor (BSF) and the air kerma to
tissue dose conversion factor, referred to here as the “f-factor”
(Note that this definition of f-factor is slightly different from
the traditional definition. The traditional definition is a con-
version factor from exposure in Roentgens to tissue dose in
rads. The definition used here is a conversion factor from air
kerma in mGy to tissue dose in mGy.). The information nec-
essary to calculate these factors can be found in the same loca-
tions as discussed previously. The beam quality, a function of
kVp and added filtration, and the x-ray field size must be used
to calculate the BSF.29, 32 The f-factor is weakly dependent on
beam quality, and for soft tissue a factor of 1.06 can safely be
used in all circumstances.29 However, in some cases the skin
may not be the tissue that experiences the highest dose, partic-
Medical Physics, Vol. 41, No. 1, January 2014
014301-14
ularly in cardiac catheterization and neurointerventional pro-
cedures. The f-factor for bone tissue is approximately 4.75,
and bone tissue lying close to the skin surface may experi-
ence higher doses than the skin.
4.D. Complicating factors
A few complicating factors must be considered when es-
timating the PSD. The first is the distribution of dose over
multiple skin sites. In some circumstances it may be possible
to distribute dose over multiple distinct sites on the skin, how-
ever, in other cases this may not be possible. A previous study
has demonstrated that avoiding overlap is particularly difficult
in interventional radiology (IR),33 owing to the large x-ray
field sizes and small geometric magnification factors used in
IR. In contrast, overlap can often be avoided in interventional
cardiology, as procedures are performed using an isocentric
geometry and smaller image receptors.34 Unless one can be
certain that dose was distributed over distinct skin sites, it is
safest to consider all dose as being delivered to the same skin
site.
A second complicating factor is the use of rotational an-
giography, also referred to as flat panel CT (FPCT) or cone
beam CT (CBCT). Rotational angiography results in the de-
livery of dose to a wide area of the skin as the x-ray source
rotates around the patient during the acquisition. The range of
angles irradiated during a rotational angiography run always
results in the delivery of a fraction of the dose to sites on the
skin distinct from the primary projection. One approach to
handling this is to measure empirical correction factors to ac-
count for this distribution.
4.E. Prevention of tissue effects
While estimating the PSD after a high dose FGI is nec-
essary in certain cases, the primary goal should be the pre-
vention of tissue effects. This requires that the physician be
aware of how much radiation has been used during the course
of a procedure. One approach to this is to set Ka,r thresholds
at which the physician is notified and certain actions taken
to ensure patient safety. This strategy was first discussed by
Wagner and Archer35 and has since been adopted by various
professional societies and as part of practice guidelines.1, 36
One method for determining Ka,r thresholds is to make mea-
surements using a phantom on the fluoroscope used to per-
form FGI. The system is configured geometrically as is typ-
ical during a case, and a dosimeter placed directly beneath
the patient phantom. A combination of irradiations using both
fluoroscopy and acquisition are performed, and the ratio of
the machine-reported Ka,r to the air kerma measured using
the dosimeter is used to calculate Ka,r thresholds that corre-
spond to certain skin doses, including backscatter (however,
the f-factor does need to be applied to the dosimeter reading).
Lead-backed dosimeters cannot be used for this purpose as
they are insensitive to backscatter.
014301-15 Jones et al.: Optimization of dose and image quality in fluoroscopy
4.F. Skin dose from multiple procedures
Occasionally a single area of a patient’s skin may be irra-
diated more than once in a short period of time. This may be
the result of a patient undergoing multiple procedures for the
same condition, two unrelated procedures, e.g., radiation ther-
apy followed by cardiac catheterization, or may occur when a
procedure expected to be complex is staged owing to concerns
of radiation dose, contrast dose, or other considerations. Ap-
pendix E of Ref. 36 covers in great detail the radiobiology of
multiple irradiation and should be consulted when such situa-
tions arise.37 Also of importance is the definition by the Joint
Commission of a dose greater than 15 Gy delivered to the
same skin site in a period of six months to a year as a sentinel
event.38
4.G. Summary
The process of estimating the PSD can be summarized in a
few simple steps. The first step is to determine the peak Ka,i .
The next step is to apply specific corrections that are func-
tions of beam quality and tissue type to estimate the PSD. Fi-
nally, any modifiers to the PSD, such as those accounting for
rotation of the C-arm or rotational angiography, are applied.
While the accuracy of the estimate depends on the available
data and its accuracy as well as the methods used, it should
be remembered that the end goal is to determine a course for
the appropriate medical management of the patient. The latest
work on radiation effects on the skin and hair stratifies effects
into broad dose “bands.”37 What is most important is that the
PSD be determined with sufficient accuracy to classify the pa-
tient into the correct band, which will then guide the medical
management of the patient.
5. RADIATION EFFECTS FROM FLUOROSCOPIC
X-RAYS
The following are established facts regarding fluoroscopic
x-rays:
1. Fluoroscopy has induced cancers in patients.39
2. Fluoroscopy has seriously injured patients.40, 41
3. Fluoroscopy has caused cancers in medical staff.42
4. Fluoroscopy has caused skin injuries in medical
staff.35
5. Fluoroscopy has caused cataracts in medical staff.43
6. Medical staff have died from disease induced by med-
ical fluoroscopy.44
7. Medical practitioners as a group are not well-versed in
the risks and exposures to patients from medical radi-
ations.
In workers, observable radiation effects are commonly
caused by the long-term accumulation of radiation dose.42 In
patients, effects are typically caused by the delivery of high
radiation doses in a short period of time,40, 41 except for poten-
tial stochastic effects which are hypothesized as being possi-
ble at any dose. Stochastic effects include induced neoplasm
and heritable genetic effects, although no heritable human ge-
Medical Physics, Vol. 41, No. 1, January 2014
014301-15
netic effects have been confirmed in descendants of exposed
persons. The following is a list of potential effects ranked ac-
cording to priority of concern in large patients. Exceptions for
small patients are noted in the list:
1. Short term (weeks to months) debilitating tissue ef-
fects, e.g., radiation-induced injury to skin and under-
lying tissues.
2. Long-term (years to decades) debilitating tissue ef-
fects, e.g., cataract, osteonecrosis.
3. Long-term stochastic risks, e.g., cancer. Typically,
long-term stochastic risks are the primary concern for
abdominal and thoracic procedures in small children.
4. Short-term cosmetic risks, e.g., depilation.
One special concern is potential effects on a conceptus,
should the patient be pregnant.45 Pregnancy tests are required
for many procedures that may potentially result in the delivery
of high doses to the uterus, e.g., hysterosalpingogram.
5.A. Radiation risks for pediatric patients
Radiation risk to pediatric patients is a special problem ow-
ing to the following:
1. Children are the most sensitive population for
radiation-induced neoplasm and malignancy;46
2. Radiation doses delivered to children with chronic
conditions are accumulated over many years and can
be very high;
3. Children vary in size from a few pounds or less to hun-
dreds of pounds.
While children are not the primary topic of this review,
their special situation must be kept in mind, realizing that ra-
diation management in children requires special techniques
that are not particularly applicable to adults. Quoting Keith
Strauss, “Children are not small adults.” The primary goal
in managing radiation to children is to ensure that radiation
is used as sparingly as possible in order to keep long-term
stochastic risks as low as reasonable. In large children, the
risk for deterministic effects is the same as it is for adults.
5.B. Lessons learned from early uses of fluoroscopy
Shortly after Röntgen discovered x-rays, the effects of ex-
posure to high doses of radiation became apparent.47, 48 At
Vanderbilt University in the United States, Professor John
Daniel was a physicist working with discharge tubes when
he read the news about Röntgen’s discovery. With his own
equipment Professor Daniel was able to acquire radiographs
of thin body parts. When asked by surgeons if he could ac-
quire a radiograph of a patient with a gunshot wound to the
head, Dr. Daniel hesitated. He decided to perform a prelim-
inary test on a volunteer. The test was unsuccessful, but the
effects of the x-ray exposure became apparent in the volun-
teer when “after 21 days all the hair fell out from the space
under the x-ray discharge, which was approximately 2 in. in
diameter.”47 This is the earliest report of an x-ray induced ef-
014301-16 Jones et al.: Optimization of dose and image quality in fluoroscopy
F IG . 5. Hands of Dr. Kassabian shortly before his death in 1910.
fect that I [LKW] have been able to find. I [LKW] have no
further follow-up regarding the loss of hair in the volunteer.
Hearing of the x-rays, Thomas Edison realized the en-
trepreneurial potential and immediately began work on devel-
oping the first fluoroscope. Clarence Madison Dally was an
assistant to Thomas Edison who had volunteered himself for
many of the experimental uses of x-rays employed during the
development of the fluoroscope. The high doses experienced
by Mr. Dally during the course of these experiments resulted
in his death from cancer in 1904, and in the eight years leading
up to his death he suffered from radiation dermatitis leading
to the amputation of both arms.44, 49
Mirhan Krikor Kassabian was a photographer who immi-
grated to the United States in the 1890s. He attended medical
school in Philadelphia. After medical school, he used his med-
ical degree and his photographic skills to become one of the
first radiologists. Dr. Kassabian would often expose his hands
to x-rays to demonstrate the uses of the fluoroscope or to eval-
uate its performance.50 By 1903 he had developed severe der-
matitis on his hands and is recorded as having said at the 1903
meeting of the American Roentgen Ray Society: “most of us
have been burned by the X-rays when using the fluoroscope
for indefinite periods. . . I hope that we will soon. . . prevent
these injuries. . . ” Dr. Kassabian is a voice from the past teach-
ing us today about the importance of making our uses of radia-
tion safe for medicine. He died of radiation-induced leukemia
at the age of 40 in 1910. Prior to his death, both of his hands
were severely damaged by the radiation and two fingers were
amputated (Fig. 5).44, 50
5.C. Establishing the link between fluoroscopic x-rays
and cancer in patients
At about the same time as the death of Dr. Kassabian, sci-
entists and others began to suspect that x-rays were the cause
of certain human tumors. In 1911 Otto Hesse51 had reported
on 94 cases of x-ray induced human tumors. Knowledge re-
garding the tumorigenic potential of x-rays came long after
knowledge about other effects because of the long latent pe-
Medical Physics, Vol. 41, No. 1, January 2014
014301-16
riod necessary for a radiation-induced tumor to advance to a
detectable disease. The shortest latent period is approximately
two years for leukemia and 5–10 years for all other cancers.52
On average, the latent period for leukemia to be diagnosed is
approximately 12–15 years and after 25 years the likelihood
of developing leukemia drops to levels near the spontaneous
incidence. For solid tumors, the average latent period is ap-
proximately 20–25 years and the excess risk is elevated for
many decades.
During the 1930s, 1940s, and 1950s, one method used to
treat pulmonary tuberculosis was to artificially collapse the
affected lung to starve the disease. To assure that the affected
lung remained collapsed, fluoroscopy was often used to exam-
ine the induced pneumothorax. During the 1960s at a sanato-
rium in Nova Scotia, Dr. I. McKenzie39 observed that there
were an unusual number of female patients with a history of
this type of treatment for pulmonary tuberculosis who had
also developed breast cancer. Dr. McKenzie launched an in-
vestigation into the probable cause and concluded that the
likely culprit was high doses of fluoroscopic x-rays. These
findings were corroborated in further research that was re-
ported in 1979.53 Dr. McKenzie’s report is the first finding
of a radiation-induced cancer subsequent to an FGI.
5.D. The United States government acts to regulate
medical x-ray use
Because of the increasing knowledge regarding the poten-
tial dangers of overexposure to x-rays, the United States Food
and Drug Adminstration (FDA) was granted authority to reg-
ulate the manufacture of x-ray producing equipment.54 By the
1960s the FDA had placed limits on fluoroscopic output, es-
tablished the use of a 5-min timer, had requirements on shield-
ing of x-ray tubes, had requirements on collimation, had es-
tablished a minimum distance between the x-ray source and
the exit port of the x-ray producing equipment, had require-
ments for shielding of the x-ray image receptor, and estab-
lished minimum requirements for filtration of the x-ray beam.
This had great success in limiting the number of reported ad-
verse events from the use of fluoroscopic x-rays.
The success of these regulations led to the development
of a false sense of security in the medical profession regard-
ing the use of fluoroscopic x-rays. Many had formed the be-
lief that fluoroscopy had been rendered perfectly safe. How-
ever, during this time procedures were brief and diagnostic
in nature. Long, complex interventional procedures were not
considered because the technology necessary to perform them
was not available. X-ray tubes would fail if pushed too hard,
and film was the only available recording technology. Thus,
technology itself limited the potential uses of fluoroscopic
x-rays.
5.E. Radiation skin injuries observed in patients
By the 1980s, technology had advanced sufficiently to
make complex FGI possible. High power generators and high
heat capacity, water cooled x-ray tubes allow the operator to
produce intense x-ray beams for long periods of time. At the
014301-17 Jones et al.: Optimization of dose and image quality in fluoroscopy
same time, a new generation of physicians without previous
experience with the consequences of high doses of fluoro-
scopic x-rays was emerging. By 1990, the first radiation injury
from an FGI had been reported.55 This would be followed by
hundreds more.1, 40, 41 While the benefit to risk ratio for the pa-
tient from FGI was clearly in favor of the benefits, the down-
side to the small percentage of patients who suffered radiation
injury was severe. These are some facts surrounding the vast
majority of these injuries:40, 41
1. The physicians involved were unaware that fluo-
roscopy could cause such an injury.
2. Use of fluoroscopy and acquisition was extensive.
3. The primary beam remained, during most of the pro-
cedure, focused on the same skin site.
4. The etiology of the injury remained undiagnosed for
months.
5. There was no attempt to monitor radiation use.
In the 22 years since the first injury, some progress has
been made in correcting the problems stated above. Many
physicians are now aware that radiation injury is a possibility,
but the number is not 100%. Many physicians are aware of the
need to manage radiation use and professional societies are
now encouraging education in this direction, and dose mon-
itoring equipment is required by the FDA on all new fluoro-
scopes. Use of dose monitoring technology, however, needs
improvement.
Radiation injury in adults from fluoroscopic x-rays has oc-
curred on most continents, has occurred in a wide variety of
anatomical locations, and has occurred during procedures per-
formed by several specialties. Few reports of radiation in-
jury exist as such injuries are not publicized owing to re-
strictions placed as terms of lawsuit settlements. Therefore, it
would be imprudent to believe that radiation injury resulting
from FGI is an isolated incident caused by any one group of
practitioners.
5.E.1. Characteristics of radiation injury
The characteristics of radiation injury are well-reviewed in
a few papers,37, 40, 41 and these characteristics will not be re-
iterated in this review. Patients demonstrate different degrees
of tolerance for radiation exposure. This might be a result of
a variety of factors, including health status, genetics, previous
radiation exposures, and medications that they might be tak-
ing. These factors are reviewed in previous papers.37, 56 Physi-
cians should be aware of these factors to be able to counsel a
patient appropriately. For example, if a patient has undergone
a previous FGI, the physician should examine the patient’s
skin for signs of a reaction from that procedure. If a skin re-
action is observed, the physician knows to avoid irradiating
the site if possible and can counsel the patient regarding the
elevated risk for a severe skin reaction from the impending
procedure.
A more recent development is the observation of osteo-
radionecrosis in patients with severe radiation skin injury.57
While this has now been observed in some patients undergo-
ing prolonged neurological intervention, it has also been ob-
Medical Physics, Vol. 41, No. 1, January 2014
014301-17
served in patients who have undergone interventional cardio-
logic procedures.58, 59 The threshold dose for osteoradionecro-
sis is very high, but the fact that the calcium matrix of bone
enhances dose over that to soft tissue by a factor of 4–5 means
that the threshold can be crossed when severe skin effects,
e.g., ulceration or necrosis, are observed.
Severe injuries have also been observed in body parts, pri-
marily the arms and shoulders, that were incidentally exposed
in the direct beam.60–62 When arms or shoulders are in the
beam, the risk for injury increases because the ADRC in-
creases x-ray output to compensate for the increased tissue
penetration thickness in the beam. Further, these body parts
are often closer to the x-ray tube and the inverse-square law
dictates increased x-ray intensity at these locations. Removal
of spacers mandated by law to maintain a minimum source-
to-skin distance can also contribute to the severity of these
injuries. Personnel who assist in procedures should be aware
of the possibility of severe injuries and should evaluate pa-
tient setup for the presence of arms or shoulders that might be
in the beam. At an appropriate moment during the procedure,
a polite observation to the operator, whose attention is likely
focused elsewhere, might help prevent a patient injury.
The diagnosis of radiation injury is relatively simple. The
following characteristics must be present to make the conclu-
sion that a skin injury was radiation-induced:
1. The absorbed dose to the skin must be high with the
radiation beam fixed mostly on the site of concern;
2. The injury must be located at the entrance beam site;
3. The temporal patterns of injury must fit with the
known temporal progression of radiation-induced
injury;37
4. The physical shape of the injury must be consistent
with the field size and collimation of the entrance
beam, with due consideration to the movement of the
beam during the procedure.
If the above characteristics of injury are observed, a biopsy
of the site is generally unnecessary and should be avoided as
it might lead to a nonhealing wound.1, 37, 40, 41
5.F. Irradiation of the female breast
During some procedures, the female breast might be in the
direct beam and in some cases may be the organ closest to the
x-ray source. The female breast is perhaps the most radiosen-
sitive organ for women under 50 years of age.46 Therefore,
careful consideration should be given when females undergo
procedures that might directly irradiate the breast tissue. It is
advisable for the physician to try to avoid direct exposure of
the breast as much as possible.
5.G. Radiation cataractogenesis
The threshold for radiation-induced cataractogenesis is
lower than previously believed. A well-designed long-term
investigation of individuals exposed to radiation after the
accident at Chernobyl has shown that the threshold for
radiation-induced cataracts is less than 0.7 Gy and could be
014301-18 Jones et al.: Optimization of dose and image quality in fluoroscopy
even lower.63 This is particularly important information for
neurointerventionalists. Tight collimation to shield as much
of the patient’s orbits and surrounding tissue as possible from
lateral beam trajectories will help reduce the long-term poten-
tial for development of radiation-induced cataract. The orbits
receive only the exit dose from a PA projection, thus limiting
the dose from that direction. This does not mean that the dose
from that direction should be discounted, however. It can be
substantial over the course of treatment for a severe condition.
This makes the avoidance of direct exposure from the lateral
trajectory all the more important.
5.H. Summary
Radiation injury to patients continues with many reports of
such occurrences in the past several years. The effects go be-
yond the physical pain and suffering of the patients. The prob-
lems caused by these injuries run much deeper, affecting the
families of patients emotionally, socially, and economically.
Daily wound dressings, restrictions on going out in public,
the economic toll of additional medical costs and associated
expenses, loss of work, and chronic pain all must be man-
aged by the patient and family members. It is very difficult
to measure whether or not education and radiation awareness
have reduced the incidence of such injuries and other radi-
ation risks. However, the severe impact of such injuries on
patients’ lives demands that vigorous efforts be made toward
improving the technological delivery of radiation, the moni-
toring of patient dose, and advancing the education of physi-
cians regarding the effective use of these tools.
Operators of fluoroscopes must also understand the risks
faced by themselves and their staff and take steps to minimize
these risks. Occupational doses, including whole body effec-
tive doses and lens doses, can be maintained ALARA by us-
ing good practice, wearing protective garments and eyewear,
and using auxiliary shielding options such as face shields and
rolling barriers.
6. FLAT PANEL COMPUTED TOMOGRAPHY
Flat panel computed tomography (FPCT) refers to the use
of an area FPD to acquire a number of projections around an
object that are used to reconstruct computed tomography (CT)
images. FPCT is a subset of cone beam CT (CBCT), which
refers to the use of a detector array sufficiently wide in the
axial (z) direction to require an x-ray source with a large cone
angle. Consider that an early 4-slice CT scanner required a
cone angle of 0.6◦ , while a modern 320-slice scanner requires
a cone angle of 8.7◦ . By comparison, an FPCT system using a
40 × 30 cm area detector requires a cone angle of 14◦ , which
is almost as large as the fan angle (18.4◦ ).
The reconstruction of images from projection data for both
equiangular and equal-spaced detector arrays has been dis-
cussed in great detail,64 as has the reconstruction of images
acquired in a cone beam geometry,65, 66 including the well-
known Feldkamp-Davis-Kress (FDK) algorithm.65 Where
FPCT image reconstruction as currently implemented in clin-
ically used systems often differs from conventional CT image
Medical Physics, Vol. 41, No. 1, January 2014
014301-18
reconstruction is in the conditioning of and corrections ap-
plied to the projection data and the absence of certain image-
space corrections. The result is that FPCT images may lack
certain characteristics inherent to conventional CT images,
for example, accurate CT numbers. Figure 6 outlines some
of the basic image reconstruction steps and highlights those
that may be absent in FPCT implementations.
FPCT implementations also face several key technological
challenges. The FDK algorithm is not exact outside the plane
of rotation, and cone beam artifacts are evident at extended
distances from the central axial plane, particularly in the form
of shading and streaks arising from flat surfaces oriented par-
allel to the central axial plane, e.g., joint surfaces. The number
of data channels that must be simultaneously read out is much
larger for a FPD used at its native resolution than for a typi-
cal conventional CT scanner. Read out noise is also higher for
FPD than for conventional CT scanners, which use ultra-low-
noise hardware. Finally, the detection of scattered radiation is
a challenge for FPCT, given the large area of the x-ray field
needed to fully irradiate the FPD.
6.A. Technical aspects of FPCT
The various implementations of FPCT on the market today
operate in a wide range of modes, and are incorporated into
a wide variety of gantry configurations, ranging from a rigid
gantry used for dental CT to a C-arm used for fluoroscopy
that has many degrees of freedom of motion. Modes of op-
eration available range from systems that use a fixed kVp,
fixed mA, and fixed pulse width to systems that vary the kVp,
mA, and pulse width to maintain the selected dose per projec-
tion (Dp ) to the detector. FPCT scans may be full-scan, i.e.,
360◦ of rotation, or half-scan, using a rotation of only 180◦
plus the width of the fan beam. FPCT implementations also
differ in the available scan field of view (SFOV). When the
FPD is aligned with the central ray of the x-ray source (i.e.,
full-fan), the SFOV at isocenter is limited by the size of the
FPD and is small compared to conventional CT, e.g., 20–25
cm for FPCT compared to 50 cm for conventional CT. The ef-
fective SFOV is increased in some FPCT implementations by
offsetting the FPD laterally from the central ray of the x-ray
source during the scan (i.e., half-fan). Using the half-fan ge-
ometry, the SFOV can be enlarged to a diameter approaching
50 cm, though a full 360◦ rotation is required. Each of these
approaches introduces unique challenges to FPCT image re-
construction and dosimetry.
6.A.1. Tube current and peak kilovoltage modulation
Some implementations of FPCT, particularly those used
in FGI applications, use tube current modulation (TCM) and
even peak kilovoltage (kVp) modulation to maintain a con-
stant Dp to the detector. These techniques are referred to
as automatic dose rate control (ADRC) or automatic expo-
sure control (AEC) when used in fluoroscopy. TCM and kVp
modulation maintain input doses at or near calibration lev-
els, avoiding noisy projection data that degrades image qual-
ity in reconstructed images. Another benefit of TCM and kVp
014301-19 Jones et al.: Optimization of dose and image quality in fluoroscopy 014301-19

F IG . 6. Reconstruction flowchart for three dimensional filtered backprojection. Steps outlined with dashed line (— — —) may be absent in FPCT. I0 calibration
is typically performed daily for conventional CT but is often performed at intervals of one year or longer in FPCT. Images in this figure courtesy of Jeffrey
H. Siewerdsen, Ph.D. (Professor, Department of Biomedical Engineering, Johns Hopkins University) and Guang-Hong Chen, Ph.D. (Professor, Departments of
Medical Physics and Radiology, University of Wisconsin).

modulation is the reduction in patient dose that results from ually in this implementation of FPCT, and are held in place
reducing x-ray intensity for low attenuation projections. by rails on the collimator window of the x-ray tube assembly.

6.A.2. Bowtie filter
Conventional CT systems use one or more bowtie filters
to shape the x-ray fluence distribution exiting the source. The
bowtie filter compensates for both changing patient dimen-
sions across the SFOV as well as the inverse square law. The
bowtie filter improves image quality by reducing scattered ra-
diation and beam hardening effects and reduces patient dose
by reducing the intensity of the x-ray beam near the edges of
the body.
Most FPCT implementations exclude the bowtie filter, ei-
ther for reasons of practicality, e.g., C-arms in the IR lab, or
in order to maintain adequate x-ray fluence with weak x-ray
tubes, e.g., dental FPCT. One manufacturer of a FPCT sys-
tem does use bowtie filters, one for a small body or head
SFOV and one for a large body SFOV. While bowtie filters are
changed automatically according to protocol or SFOV selec-
tion in conventional CT, bowtie filters must be changed man-
6.A.3. Calibration
In addition to the calibrations inherent to FPD (gain, offset,
and bad pixel), FPCT systems require geometric calibration
to account for changes in the gantry geometry during a scan.
FPCT systems, similar to conventional CT systems, require an
intensity calibration that stores values of unattenuated x-ray
intensity (I0 ) in memory for calculation of the linear attenua-
tion coefficient after the log transform is applied to measure-
ments of transmitted intensity. While intensity calibrations are
typically performed daily in conventional CT, they are often
performed less frequently for many FPCT implementations.
Other calibrations may be performed to account for beam
hardening or to scale CT numbers after image reconstruction.
Accurate image reconstruction in CT requires that the dis-
tances and angles relating the x-ray source, detector array, and
image plane be known precisely. C-arm based FPCT systems
require extensive geometric calibration67–69 to account for the
flexing of the C-arm and other changes in gantry geometry

Medical Physics, Vol. 41, No. 1, January 2014

014301-20 Jones et al.: Optimization of dose and image quality in fluoroscopy
F IG . 7. Example of bead helix phantom used for geometric calibration of
FPCT system.
that occur during FPCT scanning. The geometric calibration
process generally involves scanning a phantom with a series
of beads arranged in a spiral or other known regular pattern
(Fig. 7) to establish a mapping between a point in the im-
age and its projected location on the image receptor for each
acquired projection. The projection matrices built from these
mappings and known geometric parameters of the FPCT sys-
tem are then used to correct each projection during volumet-
ric image reconstruction (Fig. 6). As a consequence of the
need for intensity and geometry calibration and the variation
of such calibrations with changing scan parameters, certain
modes of operation may be unavailable if they have not been
calibrated by the manufacturer, and changing certain parame-
ters of the scan protocol on the fly may not be an option. For
example, changing the input dose to the detector for FPCT
may not be possible without first having the new option cali-
brated by a service engineer.
6.B. Dose in FPCT
Dose measurement in CBCT has been a topic of much dis-
cussion. A number of recent publications70–77 have addressed
the topic, culminating in the report of AAPM Task Group
111, which provided a detailed guide for assessing dose in
CBCT.77 FPCT differs from conventional CT in the fact that
there is no table movement during an FPCT scan, thus the
SFOV is limited in the axial extent to the dimensions of the
FPD projected into the plane of the isocenter. A fairly long
dosimetry phantom (e.g., a stack of three CTDI phantoms to-
taling ∼45 cm length) may be needed to completely encom-
pass the longitudinal extent of scatter tails, which are long in
FPCT owing to the z-axis extent of the x-ray beam. Fahrig
et al. discussed reference dosimetry in FPCT (Ref. 73) us-
ing a suitable “point” dosimeter, e.g., a 0.6 cm3 Farmer-type
chamber. Similarly, Daly et al. reported FPCT dosimetry in
Medical Physics, Vol. 41, No. 1, January 2014
014301-20
F IG . 8. Variation in kVp as a function of view number during a FPCT scan
of an oval-shaped phantom. The set value was 66 kVp and this FPCT system
modulates both the mA and kVp during a scan.
the context of C-arm imaging of the head and neck,74 and
Schafer et al. extended the work to dosimetry in the body (32
cm CTDI and other body dosimetry phantoms).75 Each study
demonstrated that the dose distribution within the phantom,
and in particular at the four peripheral locations within the
CTDI phantom, was nonuniform for limited-angle implemen-
tations of FPCT.
The extension of reference dosimetry to patient dosimetry
introduces some additional complicating factors. Systems op-
erating under ADRC may vary the kVp during an FPCT scan
(Fig. 8), leading to output (mGy/mAs) variations during the
scan and complicating patient-specific dosimetry.
Anderson et al., in a presentation at the 2004 Radiologi-
cal Society of North American (RSNA) meeting,78 discussed
methods that can be used to estimate patient doses based on
reference dosimetry. Their formalism used a measured fit of
output as a function of kVp to correct, projection by projec-
tion, the mAs used to acquire each frame to an equivalent mAs
at a reference kVp. This can be described as
 
kVpproj α
mAskVp
eq
ref
= mAs proj × , (5)
kVpref
where mAskVp eq
ref
is the equivalent mAs at the reference kVp,
mAsproj is the actual mAs delivered by the system for a given
projection, kVpproj is the kVp used for the same projection,
kVp ref
kVpref is the kVp at which the reference dose (Dphantom ) was
measured, and α is the exponent of a power fit of measured
output as a function of kVp. Once the mAskVp eq
ref
has been
calculated for each projection, the dose for the patient scan
(Dscan ) can be calculated as

mAskVp
eq
ref
kVp ref all frames
Dscan = Dphantom ×  . (6)
mAsproj
all frames
The measurement of reference doses in FPCT also differs
from conventional CT. For example, on many FPCT systems,
the peripheral holes in the body CTDI phantom (32 cm) are
alternately in and out of the SFOV as a consequence of the
014301-21 Jones et al.: Optimization of dose and image quality in fluoroscopy 014301-21

limited fan angle, and many FPCT implementations use a lim-

ited scan angle of 180◦ plus the fan beam width, resulting in
perturbation of the dose distribution. As a consequence, new
weighting functions will be required for calculating volume
CTDI measures in FPCT.

6.B.1. Optimizing dose in FPCT

For any modality, optimizing the radiation dose delivered
first requires knowledge of the equipment. This can be ac-
quired by reading the operator’s manual and other associ-
ated documentation, and may require negotiating access to
additional service-level documentation during the equipment
specification and purchase process. Depending on the FPCT
implementation being used, radiation dose can be optimized
through certain specific actions including:
1. Selecting the appropriate input detector Dp ;
2. Choosing the appropriate kVp based on the attenuation
of the anatomy being imaged (for systems operating
under ADRC);
3. Considering the image reconstruction and rendering
method to be used;
4. Removing unnecessary body parts from the SFOV;
5. Choosing the smallest SFOV necessary to cover the
region of interest (if SFOV adjustment is allowed by
the system); and
6. Choosing the appropriate angular sampling.
Item 1 deserves special mention as the dose “floor” of FPD
(see Sec. 3.A) must be considered when configuring the input
F IG . 9. Central axis dose Dc (0) normalized to the minimum dose as a func-
detector Dp . tion of selected kVp for a FPCT system operating under automatic control of
Different levels of image noise can be tolerated depend- both mA and kVp. (a) 16 cm CTDI phantom and (b) 32 cm CTDI phantom.
ing on the image rendering method used. For example, more The configured dose per pulse was constant at 0.36 μGy/pulse. Note that
image noise can be tolerated when rendering the images as when imaging the 32 cm CTDI phantom (part b), the kVp selected (110–120
kVp) by the ADRC algorithm in most cases exceeded the target kVp, result-
thick maximum intensity projections (MIP) for tracing blood
ing in the same Dc (0) regardless of target kVp for most targets. Such a high
supply in contrast-filled vessels than can be tolerated in 5 mm kVp was necessary to penetrate the 32 cm phantom.
axial sections used to look for fresh bleeding in the neuroin-
terventional lab. The better spatial resolution and iodine con-
trast of FPCT mean that FPCT images provide more detail the fact that a higher kVp is selected to sufficiently penetrate
than corresponding conventional CT images in some cases. thick body parts.
The impact of kVp, if selectable, on dose can be substantial.
Figure 9 plots the center axis dose (normalized to the mini-
6.C. Image quality in FPCT
mum dose) in both the 16 and 32 cm CTDI phantoms as a
function of selected kVp (i.e., the target kVp for the scan, The words “image quality” have many different meanings
actual kVp may increase if increased beam penetrability is in medical imaging. Ultimately, the images acquired must be
required during the scan owing to changing object attenua- adequate for the specific task being performed. The medical
tion) while the selected Dp remained unchanged in the FPCT physicist evaluating image quality for a FPCT system may
implementation of one manufacturer that uses ADRC during have one or more goals in mind: ensuring constancy of a
FPCT scanning. It can be seen that for small body parts (e.g., single imaging system, evaluating differences between imag-
16 cm CTDI phantom), center axis dose, Dc (0), is minimized ing systems, creating or benchmarking imaging protocols,
around 90 kVp. This result is a combination of two main standardizing clinical research, comparing equipment perfor-
factors—the penetration of the imaged body part by x-ray mance to manufacturer’s specifications at acceptance testing,
beams of differing quality and the variation in x-ray absorp- evaluating the adequacy of a FPCT imaging system for per-
tion efficiency of the image receptor as beam quality changes. forming a specific task, and/or examining the influence of
However, there is little dose savings when selecting a lower acquisition and reconstruction parameters on image quality.
kVp for imaging large body parts (e.g., 32 cm CTDI phantom) Considering these myriad goals, the tests performed should be
until the kVp nears the maximum available setting, owing to carefully selected based on the goal(s) of the evaluation, and

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014301-22 Jones et al.: Optimization of dose and image quality in fluoroscopy 014301-22

F IG . 10. Common artifacts in FPCT, including “cone beam” artifact, evi-

dent from increased blurring of disc as distance from z = 0 increases (lower
right panel). Figures courtesy of Jeffrey H. Siewerdsen, Ph.D. (Professor, De-
partment of Biomedical Engineering, Johns Hopkins University).

testing methods should be chosen to minimize inter-system

or inter-operator variability in their performance. Some tests
performed on conventional CT scanners may not be necessary
for FPCT systems, and additional tests specific to FPCT may
need to be added. Expectations that FPCT images will share
all the characteristics of conventional CT images must be ad-
justed, as these characteristics may differ markedly depending
on acquisition and reconstruction parameters.

6.C.1. Artifacts in FPCT

FPCT images may contain artifacts common to conven-
tional CT and artifacts that are unique to FPCT. Artifacts com-
mon to both FPCT and conventional CT include streaks, beam
hardening, truncation, rings, and cone beam artifacts, to name
a few (Fig. 10).79, 80 Artifacts that tend to be more prominent
in FPCT include lag artifacts, cupping artifacts, and cone-
beam artifacts. Phantoms well-suited for use in conventional
CT may require special attention when used in FPCT owing
to effects such as the “cone beam” artifact in Fig. 10, which
varies in magnitude along the z axis. Streak artifacts will be
more severe (Fig. 11) in images acquired using limited angle
scans. Subtle ring artifacts, which are inherent to FPCT where
a million or more dels contribute to an image, can degrade re-
formatted images (Fig. 12) and may necessitate a request for
more frequent calibration by the vendor of an FPCT system.
In this example of a ring artifact, an FPD gain calibration, an
FPCT I0 calibration, or both calibrations may be required.
6.C.2. Sharpness and high contrast resolution
High contrast resolution in FPCT is affected by many fac-
tors. These factors include not only technical factors related
to image acquisition and reconstruction, such as focal spot
size, reconstruction kernel, and matrix size, but also patient
motion. A single FPCT scan (i.e., rotation) requires anywhere
F IG . 11. Streak artifacts are more severe in limited angle scans owing to
the loss of conjugate rays. Artifact is less severe in (a) conventional CT (full
angle scan) than in (b) FPCT (limited angle scan).
from 5 to 30 s. Rotation speed is limited both by mechani-
cal factors, most importantly the maximum speed of gantry
rotation and braking via touch-guards, and data acquisition
and processing capability. However, the entire z-axis extent
of the scan in FPCT is covered during a single rotation, so
if the patient can remain motionless during a single rotation
they have remained motionless for the entire scan. Scan speed
can be increased and scan time decreased using one or more
of the strategies listed in Table V, keeping in mind that the
availability and usefulness of these strategies depends on the
implementation of FPCT.
It is also important that medical physicists supporting
FPCT systems understand the image reconstruction options
available, including reconstruction kernels and matrix sizes,
so they can help with the commissioning process. This may
require coordination with the vendor to locate necessary doc-
umentation describing these options, as the terminology used
may differ from the familiar terminology of conventional CT.

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014301-23 Jones et al.: Optimization of dose and image quality in fluoroscopy 014301-23

at the center of the scan volume (Fig. 10, shading). Some im-
plementations of FPCT allow the operator to collimate the x-
ray field for FPCT acquisition. As scatter decreases with the
area of the FOV, collimation is an excellent strategy to im-
prove contrast and image uniformity. Image nonuniformity,
both in terms of CT number and image noise, may also be a
consequence of limited angle scanning.

6.C.4. Lag
Lag artifacts are not commonly seen in conventional CT
owing to the very fast conversion layers used and the absence
of a thin film transistor (TFT) array for storing charge. With
FPD, both afterglow in the scintillator, a minor effect, and
charge trapping in the TFT array, a more significant effect,
can result in the inclusion of residual signal from a previous
projection in subsequent projections.79 Some manufacturers
account for lag and other effects related to charge trapping,
including sensitivity changes, during the calibration process.
Methods include performing many irradiations of the FPD
during the I0 calibration to purposely induce the effect, cre-
ating an irradiation history prior to performing any calibra-
tions of the FPCT system, or using a recursive filter correction
within the projection data directly.83, 84

6.C.5. Quantitative accuracy

One of the more striking differences between FPCT im-
ages and conventional CT images is the inaccuracy of CT
numbers measured in FPCT images (Table VI).
This is caused by several factors, including beam hard-
F IG . 12. Subtle ring artifacts that are barely visible in axial images (arrow,
ening and high SPR when scanning large body parts. kVp
lower panel) can cause substantial interference in reformatted sagittal images
(arrow, upper panel). modulation and the lack of a CT number calibration (either
air/water scaling or a more detailed calibration using mul-
tiple materials) also contribute to CT number inaccuracy in
6.C.3. Low contrast resolution and uniformity certain FPCT implementations. However, absolute quantifi-
cation using CT numbers is not necessary in many clinical
Low contrast resolution is inherently reduced in FPCT situations where FPCT is used, for example in dental imag-
compared to conventional CT owing to the relatively high ing, when creating MIPs for vascular anatomy mapping, or
readout noise of FPD (Refs. 16–18) and the high scatter-to- for 3D-3D matching in radiation oncology. Even in imple-
primary ratio (SPR) that is a consequence of the large x- mentations of FPCT that use a bowtie filter and incorporate
ray field area used in FPCT.81, 82 The high SPR also causes a separate CT number scaling calibration, CT numbers may
nonuniformities in reconstructed images, including cupping, a only be accurate when the scan conditions mimic the cali-
manifestation of the large number of scattered x-rays detected bration conditions, including patient size and shape. Caution
should be taken if absolute CT numbers are used, for exam-
ple in re-planning radiation therapy treatments. Although CT
TABLE V. Strategies for reducing scan time in FPCT.
numbers may not be absolutely accurate, FPCT systems can
Strategy Penalty still be used for quantification of contrast enhancement using
relative contrast enhancement (RCE),85 which uses relative
Use a limited angle scan differences in CT numbers measured in the same locations in
(i.e., “half scan”) instead
pre- and postcontrast scans.
of a full 360 rotation (i.e.,
“full scan”) Potential for increased streak artifacts
Reduce angular sampling Potential for increased streak artifacts 6.D. Clinical use of FPCT
Use single phase instead Potential loss of additional information FPCT has found many uses in current medical practice,
of multiphase scanninga provided by multiphase scanning both within diagnostic imaging and outside diagnostic imag-
a
In some implementations of FPCT, a postcontrast scan is performed immediately ing in areas such as image-guided interventions. FPCT is
after a precontrast scan after the gantry returns to the start position. used in IR and neurointerventional radiology to map vascular

Medical Physics, Vol. 41, No. 1, January 2014

014301-24 Jones et al.: Optimization of dose and image quality in fluoroscopy 014301-24

TABLE VI. CT numbers measured with conventional CT equipment and two FPCT systems.

Axiom Artis DynaCTa,b Axiom Artis DynaCTa,b Varian OBIb,d True CT

Material (HU kernel) (EE kernel) Sensation 64a,c (Full fan/full scan) number (70 keV)

Air − 859 − 1018 − 998 − 996 − 1000

LDPEe − 84 − 561 − 90 − 119 − 94
Acrylic 117 − 338 124 101 120
Teflon 865 598 931 963 891

Note: Calibration of the DynaCT system does not include CT number scaling, while calibration of the OBI system does include CT number scaling. CT number scaling is
standard for the Sensation 64 (conventional CT).
a
Siemens Healthcare, Malvern, PA.
b
FPCT.
c
Conventional CT.
d
Varian Medical Systems, Palo Alto, CA.
e
Low density polyethylene.

anatomy, plan complex interventions, verify therapeutic end-
points, and identify areas of active bleeding. FPCT is used
in dental clinics to plan tooth extractions or reconstructive
surgery, for example after tumor resections in the mandible
or maxilla. FPCT, when used appropriately in an in-office
setting, can provide images for diagnosing a patient’s con-
dition without the need to travel to multiple sites for diagno-
sis and treatment. FPCT is increasingly used to guide surgi-
cal interventions in the operating theatre.86, 87 FPCT has also
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ACKNOWLEDGMENTS
Stephen Balter would like to acknowledge the contribu-
tions of Una O’Connor, M.S. to his Summer School lectures
and by extension to this paper. A. Kyle Jones would like
to acknowledge the contribution of figures by Guang-Hong
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88 Estimating the required IAKR for a-Se is slightly more complicated as the
absorption characteristics of a-Se differ from CsI owing to the lower atomic
number of Se—e.g., a typical fluoroscopic x-ray spectrum will be absorbed
less efficiently by a-Se than by CsI for conversion layers of the same thick-
ness. In practice, a-Se conversion layers are often manufactured thicker
than CsI conversion layers as lateral spreading of secondary information
carriers is limited in a-Se, resulting in similar absorption efficiencies be-
tween a-Se and CsI.
89 “Fill frame” as used here has a different meaning than it does for digital
subtraction angiography (DSA). During pulsed fluoroscopy, a constant im-
age refresh rate is maintained regardless of the fluoroscopic image rate.
Frame-filling is the use of “fill frames,” which contain the same noise im-
pression and no new information, to achieve the desired refresh rate. The
integration of multiple fill frames in the HVS does not result in a reduced
perception of image noise.