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Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Distance between patient and detector
Distance between patient and detector
Distance between patient and detector
Distance between patient and detector
Distance between patient and X ray source
Distance between patient and X ray source
Distance between patient and X ray source
Distance between patient and X ray source
Distance between patient and X ray source
Distance between patient and X ray source
Tall vs
Tall vs
Patient Dose Management
Patient Dose Management
Can you tell ………
Can you tell ………
Can you tell ………
Can you tell ………
Siemens Axiom Artis, Fluoro low dose 20 cm PMMA 13
Siemens Axiom Artis, Fluoro low dose 20 cm PMMA 13
Siemens Axiom Artis, Fluoro low dose 20 cm PMMA 13
Siemens Axiom Artis, Fluoro low dose 20 cm PMMA 13
Lowest input dose needed to generate a USABLE image
Lowest input dose needed to generate a USABLE image
Lowest input dose needed to generate a USABLE image
Lowest input dose needed to generate a USABLE image
Lowest input dose needed to generate a USABLE image
Lowest input dose needed to generate a USABLE image
Each angiographic ‘run’ consists of multiple still images taken in
Each angiographic ‘run’ consists of multiple still images taken in
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Continuous fluoroscopy
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Lecture 5: Patient Dose Management
Pulsed Fluoroscopy
Pulsed Fluoroscopy
Collimation
Collimation
A word about collimation
A word about collimation
Scattered Radiation
Scattered Radiation
Scattered Radiation
Scattered Radiation
Collimation: Contrast Improvement by Reducing X ray Beam Size
Collimation: Contrast Improvement by Reducing X ray Beam Size
Equipment Selection
Equipment Selection
Equipment Selection
Equipment Selection
Dose rate dependence on image receptor active field-of-view or
Dose rate dependence on image receptor active field-of-view or
Dose rate dependence on image receptor active field-of-view or
Dose rate dependence on image receptor active field-of-view or
Image Contrast
Image Contrast
Effect of X ray Beam Penetration on Contrast, Body Penetration, and
Effect of X ray Beam Penetration on Contrast, Body Penetration, and
kVp (kiloVolt-peak)
kVp (kiloVolt-peak)
Comparison of Photon Energy Spectra Produced at Different kVp Values
Comparison of Photon Energy Spectra Produced at Different kVp Values
Filter
Filter
Filter
Filter
Dose vs
Dose vs
Dose vs
Dose vs
Dose vs
Dose vs
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Patient Dose Management

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1Patient Dose Management. L 5b. 43stochastic risk to patient by reducing
2Factors that influence Patient volume of tissue at risk Reduces scatter
Absorbed Dose. Procedural-related factors radiation at image receptor to improve
Positioning of image receptor and X ray image contrast Reduces scatter radiation
source relative to the patient Beam to in-room personnel Reduces potential
orientation and movement Collimation overlap of fields when beam is reoriented.
Acquisition and fluoroscopic technique Lecture 5: Patient Dose Management. 43.
factors on some units Fluoroscopy pulse 44Scattered Radiation. Lab Personnel.
rate Acquisition frame rate Total Patient. Operator. Two undesirable
fluoroscopy/acquisition time. Lecture 5: effects: (1) predominant source of
Patient Dose Management. 2. radiation exposure to the laboratory
3Positioning of image receptor and X personnel; Lecture 5: Patient Dose
ray source relative to the patient. Management. 44.
4Only a small percentage (typically 45Scattered Radiation. Two undesirable
~1%) penetrate through to create the effects: (2) scattered radiation that
image. Beam entering patient typically continues in the forward direction and
~100x more intense than exit beam in reaches the image receptor decreases the
average size patient. Lecture 5: Patient quality (contrast) of the image. Reduction
Dose Management. 4. of Image Contrast by Scattered Radiation.
5Inverse Square Law. X ray intensity Lecture 5: Patient Dose Management. 45.
decreases rapidly with distance from 46Collimation: Contrast Improvement by
source; conversely, intensity increases Reducing X ray Beam Size. Lecture 5:
rapidly with closer distances to source. Patient Dose Management. 46.
8.8 cm. 17.5 cm. 35 cm. 70 cm. 1 unit of 47Beam Orientation, Overlap and
intensity. 4 units of intensity. 16 units Collimation. Lesson: Reorienting the beam
of intensity. 64 units of intensity. in small increments may leave area of
Lecture 5: Patient Dose Management. 5. overlap in beam projections, resulting in
6Lecture 5: Patient Dose Management. 6. large accumulations for overlap area (red
7Inverse Square Law (1). All other area). Good collimation can reduce this
conditions unchanged, moving image effect. Lecture 5: Patient Dose
receptor toward patient lowers radiation Management. 47.
output rate and lowers skin dose rate. 48Collimation. In fact, dose at the skin
Image Receptor. Image Receptor. 4 units of entrance site increases, sometimes by a
intensity. Lecture 5: Patient Dose factor of 50% or so, depending on
Management. 7. conditions. What collimation does NOT do –
8Inverse Square Law (1). Lesson: Keep It does NOT reduce dose to the exposed
the image intensifier as close to the portion of patient’s skin. Lecture 5:
patient as is practicable for the Patient Dose Management. 48.
procedure. Image Receptor. Image Receptor. 49Factors that influence Patient
4 units of intensity. Lecture 5: Patient Absorbed Dose. Equipment-related factors
Dose Management. 8. Movement capabilities of C-arm, X ray
9Distance between patient and detector. source, image receptor Field-of-view size
Lecture 5: Patient Dose Management. 9. Collimator position Beam filtration
10Inverse Square Law (2). All other Fluoroscopy pulse rate and acquisition
conditions unchanged, moving patient frame rate Fluoroscopy and acquisition
toward or away from the X ray tube can input dose rates Automatic dose-rate
significantly affect dose rate to the control including beam energy management
skin. Lesson: Keep the X ray tube at the options X ray photon energy spectra
practicable maximum distance from the Software image filters Preventive
patient. Lecture 5: Patient Dose maintenance and calibration Quality
Management. 10. control. Lecture 5: Patient Dose
11Distance between patient and X ray Management. 49.
source. Lecture 5: Patient Dose 50Lecture 5: Patient Dose Management.
Management. 11. 50.
12Tall vs. Short Operators - Impact on 51Lecture 5: Patient Dose Management.
Patient Dose? Lecture 5: Patient Dose 51.
Management. 12. 52Field of View of Image Receptors.
13Beam Orientation. 53Equipment Selection. Angiography
14ISOCENTER. Positioning anatomy of equipment of different FOV (Field of
interest at the isocenter permits easy View). 9-inch (23 cm). 12-inch. dedicated
reorientation of the C-arm. This usually cardiac image intensifier (smaller FOV,
shortens the distance between the X ray 23-25cm) is more dose efficient than a
tube and the patient, increasing the combined cardiac / peripheral (larger FOV)
patient’s entrance port skin dose. Lecture image intensifier larger image intensifier
5: Patient Dose Management. 14. also limits beam angulation (difficult to
15ISOCENTER. When isocenter technique is obtain deep sagittal angulation ). Lecture
employed, move the image intensifier as 5: Patient Dose Management. 53.
close to the patient as practicable to 54Dose rate dependence on image receptor
limit dose rate to the entrance skin active field-of-view or magnification
surface. Lecture 5: Patient Dose mode. In general, for image intensifier,
Management. 15. the dose rate often INCREASES as the
16Beam Orientation. Physical factors and degree of electronic magnification of the
challenges to radiation management. image increases. Lecture 5: Patient Dose
Lesson: Reorienting the beam distributes Management. 54.
dose to other skin sites and reduces risk 55IMAGE INTENSIFIER. RELATIVE PATIENT
to single skin site. This is especially ENTRANCE DOSE RATE FOR SOME UNITS. Active
important in coronary angioplasty for Field-of-View (FOV). Lecture 5: Patient
chronic total occlusion. Lecture 5: Dose Management. 55.
Patient Dose Management. 16. 56How input dose rate changes with
17Overlap Areas in Beam Re-orientation. different FOVs depends on machine design
Lesson: Reorienting the beam in small and must be verified by a medical
increments may leave area of overlap in physicist to properly incorporate use into
beam projections, resulting in large procedures. A typical rule is to use the
accumulations for overlap area (red area). least magnification necessary for the
Good collimation can reduce this effect. procedure, but this does not apply to all
Reproduced with permission from Wagner LK, machines. Lecture 5: Patient Dose
Houston, TX 2004. Lecture 5: Patient Dose Management. 56.
Management. 17. 57Beam Energy, Filter & kVp.
18Beam Orientation. Conclusion: 58Image Contrast. Object silhouette with
Orientation of beam is usually determined no internal details. No object image is
and fixed by clinical need. When generated. Object image is generated.
practical, reorientation of the beam to a Lecture 5: Patient Dose Management. 58.
new skin site can lessen risk to skin. 59Effect of X ray Beam Penetration on
Overlapping areas remaining after Contrast, Body Penetration, and Dose.
reorientation are still at high risk. Good Lecture 5: Patient Dose Management. 59.
collimation reduces the overlap area. 60In general, every X ray system
Physical factors and challenges to produces a range of energies. Higher
radiation management. Lecture 5: Patient energy X ray photons ? higher tissue
Dose Management. 18. penetration. Beam energy: High energy X
19Imaging modes – Fluoroscopy, (Cine) rays: poor contrast and low skin dose. Low
Acquisition, Digital Subtraction energy X rays: high image contrast but
Angiography. high skin dose. Middle energy X rays: high
20Fluoroscopy vs Cine Acquisition. contrast for iodine and moderate skin
Influence of operation modes: from low dose. Lecture 5: Patient Dose Management.
fluoroscopy to cine, radiation / scatter 60.
dose rate could increase in a factor of 61The goal is to shape the beam energy
10-15. Lecture 5: Patient Dose Management. spectrum for the best contrast at the
20. lowest dose. An improved spectrum with 0.2
21 mm copper filtration is depicted by the
22Can you tell ………. Which image is dashes: Beam energy: Low-contrast high
FLUOROSCOPY ? Which one is ACQUISITION? energy X rays are reduced by lower kVp.
23Image Quality. Radiation Dose. Better Filtration reduces poorly penetrating low
image quality with higher radiation dose energy X rays. Middle energy X rays are
reaching the image receptor. Tradeoff: retained for best compromise on image
higher patient dose!! Lecture 5: Patient quality and dose. Lecture 5: Patient Dose
Dose Management. 23. Management. 61.
24ALARA. Physicians. Patients. 62kVp (kiloVolt-peak). kVp controls the
Professional staff. As Low As Reasonably high-energy end of the spectrum and is
Achievable. No known safe limit of usually adjusted by the system according
magnitude of radiation exposure. Lecture to patient size and imaging needs: Beam
5: Patient Dose Management. 24. energy: Reproduced with permission from
25Siemens Axiom Artis, Fluoro low dose Wagner LK, Houston, TX 2004. Lecture 5:
20 cm PMMA 13 ?Gy/fr (entrance PMMA). Patient Dose Management. 62.
Siemens Axiom Artis Cine normal mode 20 cm 63Comparison of Photon Energy Spectra
PMMA 177 ?Gy/fr (entrance PMMA). Lecture Produced at Different kVp Values. (from
5: Patient Dose Management. 25. The Physical Principles of Medical
26Lowest input dose needed to generate a Imagings, 2Ed, Perry Sprawls). Lecture 5:
USABLE image. Set the default fluoroscopy Patient Dose Management. 63.
mode to LOW. Lecture 5: Patient Dose 64Filtration. Filtration controls the
Management. 26. low-energy end of the spectrum. Some
27Duration of Fluoroscopy/Cine systems have a fixed filter that is not
Acquisition. Important to keep in mind adjustable; others have a set of filters
DURATION of fluoroscopy ? fluoroscopy x that are used under differing imaging
10-15 sec ~ cine x 1 sec. Influence of schemes. Beam energy: Reproduced with
operation modes: from low fluoroscopy to permission from Wagner LK, Houston, TX
cine, radiation / scatter dose rate could 2004. Lecture 5: Patient Dose Management.
increase in a factor of 10-15. Lecture 5: 64.
Patient Dose Management. 27. 65Filter. Lecture 5: Patient Dose
28Digital Image Subtraction (DSA). Management. 65.
Obtained by subtracting one image from 66Filtration – possible disadvantage.
another ? electronically removes (1) Advantages -- they can reduce skin
information that is identical in 2 images dose by a factor of > 2. (2)
Subtraction process accentuates image Disadvantages -- they reduce overall beam
noise ? counter this effect by acquiring intensity and require heavy-duty X ray
each of the original images at a tubes to produce sufficient radiation
substantially (up to 20x) higher dose per outputs that can adequately penetrate the
frame. Generally, studies that use DSA filters. Filters: Beam energy spectrum
employ larger aggregate doses than do before and after adding 0.2 mm of Cu
studies that employ unsubtracted filtration. Note the reduced intensity and
cinefluorography. Lecture 5: Patient Dose change in energies. To regain intensity
Management. 28. tube current must increase, requiring
29Pulsed Fluoroscopy. special X ray tube. Lecture 5: Patient
30Pulsed Fluoroscopy. Design of Dose Management. 66.
fluoroscopic equipment for proper 67Filtration –potential disadvantage. If
radiation control. Understanding Variable filters reduce intensity excessively,
Pulsed Fluoroscopy. Background: dynamic image quality is compromised, usually in
imaging captures many still images every the form of increased motion blurring or
second and displays these still-frame excessive quantum mottle (image noise).
images in real-time succession to produce Lesson: To use filters optimally, systems
the perception of motion. How these images must be designed to produce appropriate
are captured and displayed can be beam intensities with variable filter
manipulated to manage both dose rate to options that depend on patient size and
the patient and dynamic image quality. the imaging task. Lecture 5: Patient Dose
Standard imaging captures and displays 25 Management. 67.
- 30 images per second. Lecture 5: Patient 68Dose vs. Noise. Lecture 5: Patient
Dose Management. 30. Dose Management. 68.
31Each angiographic ‘run’ consists of 69Efficient Dose and Image Quality
multiple still images taken in quick Management. Achieving significant patient
succession. [ video clip]. Lecture 5: pose savings and yet keeping image quality
Patient Dose Management. 31. at the same level. Detector Dose [?GY/s].
32Continuous fluoroscopy. In Patient Dose [cGY/min]. 14. 10. 6. 2.
conventional continuous-beam fluoroscopy 0.25. 0.5. 0.75. 1. 30cm water. Lecture 5:
there is an inherent blurred appearance of Patient Dose Management. 69.
motion because the exposure time of each 70Multiple Procedures.
image lasts the full 1/30th of a second at 71Procedure Planning. Diagnostic
30 frames per second. Continuous stream of coronary angiography ? PTCA Same day?
X rays produces blurred images in each Different day? Multivessel PTCA Treat all
frame. Images. 30 images in 1 second. X lesions during same procedure? Staged
rays. Lecture 5: Patient Dose Management. PTCA? Restenosis, Repeat Procedures.
32. Lecture 5: Patient Dose Management. 71.
33Lecture 5: Patient Dose Management. 72“Dose Fractionation” in Interventional
33. Cardiology. Reduce deterministic risk
34Pulsed Fluoroscopy. Fluoroscopic think of it as similar to risk of
pulsing X rays are produced during a small contrast-related nephropathy No
portion of the video frame time. The significant impact on stochastic risk (?
narrower the pulse width, the sharper the cumulative effective dose). Lecture 5:
image. (? “Faster shutter speed” in camera Patient Dose Management. 72.
). Lecture 5: Patient Dose Management. 34. 73Effect. Dose. Deterministic effects.
35Pulsed Fluoroscopy. Physical factors Stochastic. Cataract Infertility Erythema
and challenges to radiation management. Epilation. Cancer Genetic Prob ? dose.
Pulsed imaging controls: Displaying 25–30 Lecture 5: Patient Dose Management. 73.
picture frames per second is usually 74Lab Personnel. Patient. Operator.
adequate for the transition from frame to Measures taken to reduce radiation
frame to appear smooth. This is important exposure to patient will also benefit the
for entertainment purposes, but not operator/cath lab staff. Lecture 5:
necessarily required for medical Patient Dose Management. 74.
procedures. Manipulation of frame rate can 75Revision Qs: “True” or “False”? The
be used to produce enormous savings in higher the kVp, the higher the energy of
dose accumulation. Lecture 5: Patient Dose the X ray photons, and the more contrast
Management. 35. is the X ray image. When acquiring
36Lecture 5: Patient Dose Management. angiography with image intensifier, it is
36. always better to use as magnified a
37Lecture 5: Patient Dose Management. field-of-view (FOV) as possible, because
37. more details can be visualized. Lecture 5:
38Lecture 5: Patient Dose Management. Patient Dose Management. 75.
38. 76Revision Qs: “True” or “False”? To
39Variable Pulsed Fluoroscopy. Lesson: avoid physical injury to patient, and to
Variable pulsed fluoroscopy is an facilitate C-arm movement, it is advisable
important tool to manage radiation dose to to keep the image receptor as far away
patients but the actual effect on dose can from patient as possible. Patient has
be to enhance, decrease or maintain dose complex triple-vessel disease for
levels. The actual effect must be angioplasty/stenting. Doing the
estimated by a qualified physicist so that angioplasty for all narrowings in one
variable pulsed fluoroscopy can be procedure will increase the risk of
properly employed. Design of fluoroscopic deterministic radiation injuries. Lecture
equipment for proper radiation control. 5: Patient Dose Management. 76.
Lecture 5: Patient Dose Management. 39. 77Revision Qs: “True” or “False”?
40Collimation. Scattered radiation has no impact on the X
41Collimation. Lecture 5: Patient Dose ray image quality. Angiography table
Management. 41. should be kept as near to the X ray source
42A word about collimation. What does as possible. Keeping the same pulse
collimation do? Collimation confines the X intensity, reducing fluoroscopy pulse rate
ray beam to an area of the user’s choice. from 30 to 15 pulses/sec will reduce
Lecture 5: Patient Dose Management. 42. radiation dose to patient by 50%. Lecture
43Collimation. Why is narrowing the 5: Patient Dose Management. 77.
field-of-view beneficial? Reduces
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