View source for X-ray image intensifier

{{Short description|Image intensifier that converts x-rays into visible light at higher intensity}}
{{more citations needed|date=June 2010}}

An '''X-ray image intensifier''' (XRII) is an [[image intensifier]] that converts [[X-ray]]s into visible light at higher [[intensity (physics)|intensity]] than the more traditional [[fluorescence|fluorescent]] screens can. Such intensifiers are used in X-ray imaging systems (such as [[fluoroscopy|fluoroscopes]]) to allow low-intensity X-rays to be converted to a conveniently [[brightness|bright]] visible light output. The device contains a low absorbency/scatter input window, typically aluminum, input fluorescent screen, photocathode, electron optics, output fluorescent screen and output window. These parts are all mounted in a high vacuum environment within glass or, more recently, metal/ceramic. By its [[amplifier|intensifying]] effect, It allows the viewer to more easily see the structure of the object being imaged than fluorescent screens alone, whose images are dim. The XRII requires lower [[absorbed dose]]s due to more efficient conversion of X-ray quanta to visible light. This device was originally introduced in 1948.<ref>{{cite book|last=Krestel|first=Erich|title=Imaging Systems for Medical Diagnostics|year=1990|publisher=Siemens Aktiengesellschaft|location=Berlin and Munich|isbn=3-8009-1564-2|pages=318–327}}</ref>

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==Operation==
[[File:XiiSchematic.jpg|thumb|right|Schematic of an X-ray image intensifier]]
The overall function of an image intensifier is to convert incident x-ray photons to light photons of sufficient intensity to provide a viewable image. This occurs in several stages. The input window is convex is shape, made up of aluminium to minimise the scattering of X-rays. The window is 1 mm in thickness. Once X-rays pass through the aluminium windows, it encounters input [[phosphor]] that converts X-rays into light photons. The thickness of input phosphor range from 300 to 450 micrometres reach a compromise between absorption efficiency of X-rays and spatial resolution. Thicker input phosphor has higher absorption efficiency but poor spatial resolution and vice versa. Sodium activated Caesium Iodide is typically used due to its higher conversion efficiency thanks to high [[atomic number]] and [[mass attenuation coefficient]], when compared to zinc-cadmium sulfide. The input phosphor are arranged into small tubes, to allow photons to pass through the tube, without scattering, this improving the spatial resolution.<ref name="AAPMRSNA">{{cite journal|last1=Wang|first1=Jihong|last2=Blackburn|first2=Timothy J.|title=The AAPM/RSNA Physics Tutorial for Residents|journal=RadioGraphics|date=September 2000|volume=20|issue=5|pages=1471–1477|doi=10.1148/radiographics.20.5.g00se181471|pmid=10992034|doi-access=}}</ref> The light photons are then converted to [[electron]]s by a photocathode. The photocathode is made up of antimony caesium, which is to match the photons produced from input phosphor, thus maximise the efficiency of producing photoelectrons. The photocathode has a thickness of 20 nm with absorption efficacy of 10 to 15%.<ref name="AAPMRSNA"/>

A [[potential difference]] (25-35 kilovolts) created between the anode and photocathode then accelerates these photoelectrons while [[electron lens]]es focus the beam down to the size of the output window. The output window is typically made of silver-activated zinc-cadmium sulfide and converts incident electrons back to visible light photons.<ref name="AAPMRSNA" /> At the input and output phosphors the number of photons is multiplied by several thousands, so that overall there is a large brightness gain. This gain makes image intensifiers highly sensitive to X-rays such that relatively low doses can be used for fluoroscopic procedures.<ref>{{cite book|last1=Hendee|first1=William R.|last2=Ritenour|first2=E. Russell|title=Medical Imaging Physics|date=2002|publisher=John Wiley & Sons|location=Hoboken, NJ|isbn=9780471461135|page=237|edition=4th}}</ref><ref>{{cite journal|last1=Schagen|first1=P.|title=X-Ray Image Intensifiers: Design and Future Possibilities|journal=Philosophical Transactions of the Royal Society A: Mathematical, Physical and Engineering Sciences|date=31 August 1979|volume=292|issue=1390|pages=265–272|doi=10.1098/rsta.1979.0060|bibcode=1979RSPTA.292..265S|s2cid=122975544}}</ref><ref>{{cite book|editor-last1=Bronzino|editor-first1=Joseph D.|title=Medical Devices and Systems.|date=2006|publisher=CRC Press|location=Hoboken|isbn=9781420003864|pages=10–5|edition=3rd}}</ref><ref>{{cite book|last1=Singh|first1=Hariqbal|last2=Sasane|first2=Amol|last3=Lodha|first3=Roshan|title=Textbook of Radiology Physics|date=2016|publisher=JP Medical|location=New Delhi|isbn=9789385891304|page=31}}</ref>

==History==

X-ray image intensifiers became available in the early 1950s and were viewed through a microscope.<ref>{{cite journal|last1=Airth|first1=G. R.|title=X-Ray Image Intensifiers: Applications and Current Limitations|journal=Philosophical Transactions of the Royal Society A: Mathematical, Physical and Engineering Sciences|date=31 August 1979|volume=292|issue=1390|pages=257–263|doi=10.1098/rsta.1979.0059|bibcode=1979RSPTA.292..257A|s2cid=119912616}}</ref>

Viewing of the output was via mirrors and optical systems until the adaption of television systems in the 1960s.<ref>{{cite web|title=Radiography in the 1960s|url=http://www.bir.org.uk/patients-public/history-of-radiology/1960s/1960s-radiography/|website=British Institute of Radiology|access-date=5 January 2017}}</ref> Additionally, the output was able to be captured on systems with a 100mm cut film camera using pulsed outputs from an X-ray tube similar to a normal radiographic exposure; the difference being the II rather than a film screen cassette provided the image for the film to record.

The input screens range from 15–57&nbsp;cm, with the 23&nbsp;cm, 33&nbsp;cm and 40&nbsp;cm being among the most common. Within each image intensifier, the actual field size can be changed using the voltages applied to the internal electron optics to achieve magnification and reduced viewing size. For example, the 23&nbsp;cm commonly used in cardiac applications can be set to a format of 23, 17, and 13&nbsp;cm. Because the output screen remains fixed in size, the output appears to "magnify" the input image.  High-speed digitalisation with analogue video signal came about in the mid-1970s, with pulsed fluoroscopy developed in the mid-1980s harnessing low dose rapid switching X-ray tubes. In the late 1990s image intensifiers began being replaced with flat panel detectors (FPDs) on fluoroscopy machines giving competition to the image intensifiers.<ref name=":0">{{cite journal|last1=Seibert|first1=J. Anthony|title=Flat-panel detectors: how much better are they?|journal=Pediatric Radiology|date=22 July 2006|volume=36|issue=S2|pages=173–181|doi=10.1007/s00247-006-0208-0|pmc=2663651|pmid=16862412}}</ref>

==Clinical applications==

{{main article|Fluoroscopy}}

"C-arm" mobile fluoroscopy machines are often colloquially referred to as [[image intensifiers]] (or IIs),<ref>{{cite book|editor1-last=Krettek|editor1-first=Christian|editor2-last=Aschemann|editor2-first=Dirk|title=Positioning Techniques in Surgical Applications|date=2006|publisher=Springer|location=Berlin|isbn=978-3-540-25716-5|page=21|chapter=Use of X-rays in the operating suite|doi=10.1007/3-540-30952-7_4}}</ref> however strictly speaking the image intensifier is only one part of the machine (namely the detector).

Fluoroscopy, using an X-ray machine with an image intensifier, has applications in many areas of medicine. Fluoroscopy allows live images to be viewed so that [[image-guided surgery]] is feasible. Common uses include [[orthopedics]], [[gastroenterology]] and [[cardiology]].<ref>{{cite web|title=Fluoroscopy: Background, Indications, Contraindications|url=http://emedicine.medscape.com/article/1890603-overview#a2|website=Medscape|access-date=5 January 2017|date=7 April 2016}}</ref> Less common applications can include [[dentistry]].<ref>{{cite journal|last1=Uzbelger Feldman|first1=D|last2=Yang|first2=J|last3=Susin|first3=C|title=A systematic review of the uses of fluoroscopy in dentistry |journal=Chinese Journal of Dental Research|date=2010|volume=13|issue=1|pages=23–9|pmid=20936188}}</ref>

===Configurations===
[[File:Mobile X-ray image intensifier.JPG|thumb|right|C-arm of a mobile X-ray unit containing an image intensifier (top)]]
A system containing an [[image intensifier]] may be used either as a fixed piece of equipment in a dedicated screening room or as mobile equipment for use in an [[operating theatre]]. A mobile fluoroscopy unit generally consists of two units, the [[X-ray generator]] and image detector (II) on a moveable C-arm, and a separate workstation unit used to store and manipulate the images.<ref>{{cite web|title=Fluoroscopy: Mobile Unit Operation and Safety|url=http://static.crowdwisdomhq.com/asrt/documents/Fluoro_Previews/Fluoro_4_MobileUnit_SAMPLE.pdf|website=American Society of Radiologic Technologists|access-date=21 May 2017}}</ref> The patient is positioned between the two arms, typically on a [[Radiodensity|radiolucent]] bed. Fixed systems may have a c-arm mounted to a ceiling gantry, with a separate control area. Most systems arranged as c-arms can have the image intensifier positioned above or below the patient (with the X-ray tube below or above respectively), although some static in room systems may have fixed orientations.<ref>{{cite book|last1=Bushberg|first1=Jerrold T.|last2=Seibert|first2=J. Anthony|last3=Leidholdt|first3=Edwin M.|last4=Boone|first4=John M.|title=The Essential Physics of Medical Imaging|date=28 December 2011|publisher=Lippincott Williams & Wilkins|isbn=9781451153941|page=283|url=https://books.google.com/books?id=RKcTgTqeniwC&pg=PA283|language=en}}</ref> From a [[radiation protection]] standpoint, under-couch (X-ray tube) operation is preferable as it reduces the amount of [[scattering|scattered]] radiation on operators and workers.<ref>{{cite book|last1=Smith|first1=Arthur D.|title=Smith's Textbook of Endourology|year=2007|publisher=PMPH-USA|isbn=9781550093650|page=13|url=https://books.google.com/books?id=Wo8cgdAsL-EC&pg=PA13|language=en}}</ref><ref>{{cite journal|last1=Mitchell|first1=Erica L.|last2=Furey|first2=Patricia|title=Prevention of radiation injury from medical imaging|journal=Journal of Vascular Surgery|date=January 2011|volume=53|issue=1|pages=22S–27S|doi=10.1016/j.jvs.2010.05.139|pmid=20843625|doi-access=free}}</ref> Smaller "mini" mobile c-arms are also available, primarily used to image extremities, for example for minor [[hand surgery]].<ref>{{cite journal|last1=Athwal|first1=George S.|last2=Bueno|first2=Reuben A.|last3=Wolfe|first3=Scott W.|title=Radiation Exposure in Hand Surgery: Mini Versus Standard C-Arm|journal=The Journal of Hand Surgery|date=November 2005|volume=30|issue=6|pages=1310–1316|doi=10.1016/j.jhsa.2005.06.023|pmid=16344194}}</ref>

===Flat panel detectors===
{{main article|Flat panel detector}}
Flat Detectors are an alternative to Image Intensifiers. The advantages of this technology include: lower patient dose and increased image quality because the X-rays are always pulsed, and no deterioration of the image quality over time.  Despite FPD being at a higher cost than II/TV systems, the noteworthy changes in the physical size and accessibility for the patients is worth it, especially when dealing with paediatric patients.<ref name=":0" />

====Feature comparison of II/TV and FPD Systems====
{| class="wikitable"
!Feature<ref name=":0" />
!Digital Flat Panel
!Conventional II/TV
|-
|Dynamic range
|Wide, about 5,000:1
|Limited by TV, about500:1
|-
|Geometric distortion
|None
|Pin-cushion and ‘S-distortion
|-
|Detector size (bulk)
|Thin profile
|Bulky, significant with large FOV
|-
|Image area FOV
|41 x 41&nbsp;cm
|40&nbsp;cm diameter (25% less area)
|-
|Image quality
|Better at high dose
|Better at low dose
|}

==See also==
* {{annotated link|X-ray detector}}
* {{annotated link|Rotational angiography}}

==References==
{{Reflist}}

{{DEFAULTSORT:X-Ray Image Intensifier}}
[[Category:X-rays|Image]]
[[Category:Radiography]]
[[Category:X-ray instrumentation|Image]]
[[Category:Medical imaging]]