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‫بسم هللا الرحمن الرحيم‬

‫السالم عليكم ورحمة هللا وبركاته‬ Pendahuluan

• History of Medical Imaging

Medical Imaging • Physical Signals
Basic Imaging Principles: Introduction • Imaging Modalities
• Projection Radiography
• Computed Tomography
Amir Faisal, S.T., M.Eng., Ph.D. • Nuclear Medicine
Teknik Biomedik • Ultrasound Imaging
Jurusan Teknologi Produksi & Industri • Magnetic Resonance Imaging
• Multimodality Imaging
Institut Teknologi Sumatera

History of Medical Imaging

• We take a signals and systems approach to the characterization • The first published medical image was a radiograph of the hand
of medical imaging. of Wilhelm Conrad Roentgen’s wife in December 1895.
• There are a variety of signals in which we are interested; • Roentgen had been experimenting with a Crooke’s tube (the
ultimately, this interest stems from the biological and medical forerunner of today’s x-ray tube) and noticed that ‘‘a new kind of
significance of these signals in patients with various diseases. rays’’ (hence, x-rays) were emitted that could expose a
• In practice, these signals are transformed into images via photographic plate even when optically shielded.
medical imaging modalities. • It was immediately obvious to Roentgen that his discovery could
• We begin to consider these modalities and their characteristics. have a profound impact in medicine.
• Indeed, the first clinical use of x-rays occurred only two months
later, in February 1896.

• The use of x-rays became widespread, and both static and • Godfrey Hounsfield produced the first true computed
dynamic (fluoroscopic) techniques were developed. tomography (CT) scanner in 1972 at EMI in England.
• Here, a static technique refers to an image taken at a single • He used mathematical methods for image reconstruction
point in time, whereas a dynamic technique refers to a series of developed a decade earlier by Allan Cormack of the United
images acquired over time. States.
• For many decades, these planar (i.e., two-dimensional • Hounsfield and Cormack shared the Nobel Prize in Medicine in
projection) radiographs were the only medical images being 1979.
produced. • Many radiologists consider CT scanning to be the most
• Ultimately, radiography was extended into transmission important development in medical imaging since Roentgen’s
computed tomography, or cross-sectional imaging. original discovery.

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• As radiography arose from the discovery of x-rays, nuclear • A radiotracer is a radioactively labeled drug that mimics a
medicine arose from the discovery of radioactivity by Antoine biological compound of interest; the distribution of the
Henri Becquerrel in 1896. radioactivity implies the distribution of the drug.
• Initially, radionuclides were used in cancer therapy rather than • Early studies with radiotracers used conventional nonimaging
in medical imaging. radiation detectors to roughly determine amounts of
• The concept of using radioactive tracers to study physiology radioactivity in various body regions. In 1949, Benedict Cassen
was introduced by George de Hevesy in 1923; de Hevesy is at UCLA started the development of the first imaging system in
considered the father of nuclear medicine. nuclear medicine, the rectilinear scanner.
• The modern Anger scintillation camera was developed by Hal
Anger at UC Berkeley in 1952.

• The element of the most commonly used radionuclide in nuclear • Ultrasound technology progressed through the 1960s from A-
medicine, technetium-99m, was discovered in 1937 by Carlo mode, B-mode, and M-mode scans to today’s two-dimensional
Perrier and Emilio Segre; its first use in medicine was in 1961. (2-D) Doppler, three-dimensional (3-D), and nonlinear imaging
• The interaction of acoustic waves with media was first systems.
described by Lord John Rayleigh over one hundred years ago • The phenomenon of nuclear magnetic resonance, from which
in the context of the propagation of sound in air. magnetic resonance imaging (MRI) arises, was first described
• Modern ultrasound imaging had its roots in World War II Navy by Felix Bloch and Edward Purcell; they shared the 1952 Nobel
sonar technology, and initial medical applications focused on Prize in Physics.
the brain. • This work was extended by Richard Ernst, who received the
Nobel Prize in Chemistry in 1991.

Physical Signals

• In 1971, Raymond Damadian published a paper suggesting the • We consider the detection of different physical signals arising
use of magnetic resonance (MR) in medical imaging; in 1973, a from the patient and their transformation into medical images.
paper by Paul Lauterbur followed. • In practice, these signals arise from four processes:
• Lauterbur received the Nobel Prize in Medicine in 2003, along • Transmission of x-rays through the body (in projection radiography and
with Peter Mansfield, who developed key methods in MRI. CT)
• Emission of gamma rays from radiotracers in the body (in nuclear
medicine)
• Reflection of ultrasonic waves within the body (in ultrasound imaging)
• Precession of spin systems in a large magnetic field (in MRI)

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• Radiography, CT scanning, and nuclear medicine all make use • At long wavelengths—for example, longer than 1 angstrom—
of electromagnetic energy. most electromagnetic energy is highly attenuated by the body,
• Electromagnetic energy or waves consist of electric and prohibiting its exit and external detection.
magnetic waves traveling together at right angles. • At wavelengths shorter than about 10−2 angstroms, the
• Wavelength and frequency are inversely related; frequency and corresponding energy is too high to be readily detected.
energy are directly related. • We express energy in units of electron volts (eV), where 1 eV is
• The electromagnetic spectrum spans the frequency range from the amount of energy an electron gains when accelerated
zero to that of cosmic rays; only a relatively small portion of this across 1 volt potential.
spectrum is useful in medical imaging. • We will concentrate on electromagnetic radiation whose
wavelengths correspond to energies of roughly 25–500 keV.

• Ultrasound imaging utilizes sound waves, and considerations of • The signal in MRI arises from the precession (like the motion of
attenuation and detection are similar to those above. a child’s top or dreidel) of nuclei of the hydrogen atom—that is,
protons.
• Image resolution is not adequate when wavelengths longer than
a couple of millimeters are used, and attenuation is too high for • When placed in a large magnetic field, collections of protons,
termed spin systems, can be set into motion by applying radio
very short wavelengths. frequency (RF) currents through wire coils surrounding the
• An ideal frequency range for ultrasound in medical imaging is patient.
1–20 MHz, where 1 Hz = 1 cycle/second. • Although these spin systems process at RF frequencies (64
MHz is typical), the primary signal source is not from radio
waves, but from the Faraday induction of currents in the same
or different wire coils.

Imaging Modalities

• The medical imaging areas we consider in detail in this book • The first two transmit x-rays through the body, then use the fact
are projection radiography, CT, nuclear medicine, ultrasound that the body’s tissues selectively attenuate (reduce) the x-ray
imaging, and MRI. intensities to form an image.
• An imaging modality is a particular imaging technique or system • These are termed transmission imaging modalities because
within one of these areas. they transmit energy through the body.
• In this section, we give a brief overview of these most common • In nuclear medicine, radioactive compounds are injected into
imaging modalities. the body.
• Projection radiography, CT, and nuclear medicine all use • These compounds or tracers move selectively to different
ionizing radiation. regions or organs within the body, emitting gamma rays with
intensity proportional to the compound’s local concentration.

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• Nuclear medicine methods are emission imaging modalities • MRI requires a combination of a high-strength magnetic field
because the radioactive sources emit radiation from within the and radio frequency Faraday induction to image properties of
body. the proton nucleus of the hydrogen atom.
• Ultrasound imaging transmits high-frequency sound into the • This technique is called magnetic resonance imaging since it
body and receives the echoes returning from structures within exploits the property of nuclear magnetic resonance.
the body.
• This method is often called reflection imaging because it relies
on acoustic reflections to create images.

Projection Radiography

• Projection radiography includes the following modalities: • Neuroradiology, which includes specialized x-ray systems for
• Routine diagnostic radiography, including chest x-rays, precision studies of the skull and cervical spine
fluoroscopy, mammography, and motion tomography (a form of • Mobile x-ray systems, which are small x-ray units designed for
tomography that is not computed tomography) operating rooms or emergency vehicles
• Digital radiography, which includes all the scans in routine • Mammography, which includes film-based or digital-based
radiography, but with images that are recorded digitally instead systems optimized for breast imaging
of on film • All of these modalities are called ‘‘projection’’ radiography
• Angiography, including universal angiography and because they all represent the projection of a 3-D object or
angiocardiography, in which the systems are specialized for signal onto a 2-D image.
imaging the body’s blood arteries and vessels

• The common element in all of these systems is the x-ray tube. • This intensity distribution is revealed using a scintillator, which
• The x-ray tube generates an x-ray pulse in an approximately converts the x-rays to visible light.
uniform ‘‘cone beam’’ (shaped like a cone) geometry. • The light image on the scintillator is captured either on a large
• This pulse passes through the body and is attenuated by the sheet of photographic film, a camera, or solid-state detectors.
intervening tissues. • The most common modality in projection radiography is the
• The x-ray intensity profile across the beam exiting from the chest x-ray; a typical unit is shown in Figure 1.1(a).
body is no longer uniform—shadows have been created by • Here, the x-ray tube is located on the column projecting down
dense objects (such as bone) in the body. from the ceiling. The scintillator and detector can be located
either in the pedestal unit on the right or in the table itself.

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• The radiologic technologist stands at a console not shown, • This is a property of projection imaging, and it is common to all
protected by lead, but able to see through a window. projection radiographic methods.
• A typical chest x-ray is shown in Figure 1.1(b). • True tomography, the imaging of a 2-D slice of the 3-D body,
• This image shows the spine, ribs, heart, lungs, and many other cannot be directly accomplished using any modality in
features radiologists are trained to identify and interpret. projection radiography.
• A key feature of this image is that structures located at different • More details about projection radiography are given in Chapter
depths in the body are overlaid (or superimposed) on the 2-D 5.
image.
• For example, we can see both front and back ribs in the chest
x-ray in Figure 1.1(b).

Computed Tomography

• As in projection radiography, CT uses x-rays.

• Unlike projection radiography, however, CT collects multiple
(a) A chest x-ray projections of the same tissues from different orientations by
unit and moving the x-ray source around the body.
(b) a chest x-ray • CT systems have rows of digital detectors whose signals are
image. input directly to a computer, and these signals are used to
reconstruct one or more cross sections (slices) of the human
body.
• In this way, although CT systems acquire projections that
represent a ‘‘shadow’’ of the body, they generate truly
tomographic images after reconstruction.

• The important historical phases in CT development are single- • The importance of this technique is in its ability to rapidly
slice CT, helical CT, and multiple-row detector CT (MDCT). acquire 3-D data, such as a whole body scan, in less than a
• Single-slice CT systems acquire data within a single plane and minute.
reconstruct only one plane per rotation. • In MDCT systems, there are many rows of detectors used to
• In helical CT systems, the x-ray tube and detectors continuously rapidly gather a cone of x-ray data, comprising a 2-D projection
rotate around in a large circle, while the patient is moved in a of the 3-D patient.
continuous motion through the circle’s center. • When the x-ray source and detectors revolve rapidly around the
• From the patient’s perspective, the x-ray tube carves out a patient (one to two revolutions per second), very quick (near
helix; hence, the name helical CT. real-time) 3-D imaging is possible using these CT scanners.

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• A typical CT scanner is shown in Figure 1.2(a). • Although CT images can be printed on paper or film, the images
• In the center of the picture, we can see the cylindrical opening are completely digital in nature since they are computed from
in which the patient lies; a patient table is also visible. the measured projections.
• Around the cylindrical opening is a housing containing both the • The CT image shown in Figure 1.2(b) is a slice through the
x-ray tube and the detector array. liver; the data used to reconstruct this image were acquired in
just one second.
• The gantry holding these components is capable of spinning
rapidly around the patient. • Computed tomography is described in more detail in Chapter 6.
• The computer displays and keyboard in the foreground are
used for entering patient data and viewing images.

Nuclear Medicine

• Nuclear medicine imaging is distinguished from all other

medical imaging modalities by the fact that images can only be
made when appropriate radioactive substances are introduced
(a) A CT scanner into the body.
and • These substances, which are either injected, ingested, or
(b) a CT image of inhaled into the body, are trace amounts of biochemically active
a slice through drugs whose molecules are labeled with radionuclides that emit
the liver. gamma rays.
• These so-called radiotracers move within the body according to
the body’s natural uptake of the biological carrier molecule.

• For example, radioactive iodine can be used to study thyroid • There are three modalities within nuclear medicine:
function. conventional radionuclide imaging or scintigraphy, single-photon
• A nuclear medicine image reflects the local concentration of a emission CT (SPECT), and positron emission tomography
radiotracer within the body. (PET).
• Since this concentration is tied to the physiological behavior of • Conventional radionuclide imaging and SPECT typically utilize a
the carrier molecule within the body, nuclear medicine imaging special 2-D gamma ray scintillation detector called an Anger
is an example of a functional imaging method, whereas camera.
standard CT and MRI are anatomical or structural imaging • This camera is designed to detect single x-rays or gamma rays,
methods. rather than simply detecting the intensity of a collective beam as
in projection radiography and CT.

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• In conventional radionuclide imaging, this camera is • SPECT and PET produce images of slices within the body.
conceptually analogous to the film or digital detector in SPECT does this by rotating the Anger camera around the
projection radiography. body.
• A complication is that this procedure combines the effects of • Since the Anger camera is a 2-D imager, SPECT is
emission with the effects of attenuation of the rays by fundamentally a 3-D imaging technique.
intervening body tissues, producing images that are 2-D • In conventional radionuclide imaging and SPECT, a radioactive
projections of the 3-D distribution of radiotracers (which we wish atom’s decay produces a single gamma ray, which may
to know) confounded by attenuation. intercept the Anger camera.

• In PET, however, a radionuclide decay produces a positron, • A SPECT scanner is shown in Figure 1.3(a).
which immediately annihilates (with an electron) to produce two • The Anger camera at the top (and side) is capable of rotating
gamma rays flying off in opposite directions. completely around the patient, who lies on the table.
• The PET scanner looks for coincident detections from opposing • The table can move in coordination with the camera (for a
detectors in its ring, thus determining the line that passes helical tomographic scan), or the table can move with a
through the site where the annihilation occurred. stationary camera (for a whole-body standard projection scan).
• Both SPECT and PET use computed tomography • The collection of SPECT images shown in Figure 1.3(b) are
reconstruction techniques including iterative reconstruction in cardiac scans taken at different spatial positions in the heart
order to create diagnostic images. depicting blood flow to the heart muscle. Nuclear medicine
imaging is described in more detail in Chapters 7 through 9.

Ultrasound Imaging

(a) A SPECT scanner and • Ultrasound imaging uses electrical-to-acoustical transducers to

(b) a series of SPECT heart scans. generate repetitive bursts of high-frequency sound.
• These pulses travel into the soft tissue of the body and reflect
back to the transducer.
• The time-of-return of these pulses gives information about the
location (depth) of a reflector, and the intensity of these pulses
gives information about the strength of a reflector.
• By rapidly moving or scanning the transducer or its acoustical
beam, real-time images of cross sections of soft tissue can be
generated.

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• Ultrasound imaging systems are comparatively inexpensive and • Ultrasound imaging systems offer several imaging modalities:
completely non-invasive; therefore, these systems are • A-mode imaging, which generates a one-dimensional
widespread and in common usage. waveform, and as such does not really comprise an image. This
• They are designed primarily to image anatomy and, although mode, however, can provide very detailed information about
their image quality in some ways is not as good as other rapid or subtle motion (e.g., of a heart valve).
anatomical imaging modalities such as CT and MRI, they are • B-mode imaging, which is ordinary cross-sectional anatomical
real-time and highly adaptable to a wide variety of imaging imaging.
goals.
• There are several arrangements of transducers that can give
rise to images with different appearances.

• M-mode imaging, which generates a succession of A-mode • Doppler imaging, which uses the property of frequency or phase
signals, brightness modulated and displayed in real time on a shift caused by moving objects (like a police siren that has a
computer display. higher frequency when approaching and a lower frequency
when departing) to generate images that are color coded by
• M-mode generates an image that does not represent a cross their motion.
section of anatomy but is important for measuring time-varying • Doppler is most commonly used, however, in an audio mode.
displacements of, for example, a heart valve.
• Running the frequency shifts through speakers allows an aural
analysis of motion which is not possible with a visual display.
• Nonlinear imaging, which permits higher resolution imaging at
greater depths and also permits imaging certain tissue
properties.

• An ultrasound imaging system is shown in Figure 1.4(a).

(a) An ultrasound
• In addition to being inexpensive, ultrasound systems are small;
scanner and (b) an most systems are on wheels, and can be rolled to the bedside
ultrasound image of a or wherever needed.
kidney. • Very compact systems with limited functionality comprising just
a transducer and a tablet or a smart phone are currently being
marketed.
• Two transducers are shown in the figure, with their connecting
cables; only one is used at any given time.

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Magnetic Resonance Imaging

• Transducers with differing frequencies and geometries are • Magnetic resonance (MR) scanners use the property of nuclear
usually available to serve the examination requirements. magnetic resonance to create images.
• The ultrasound image shown in Figure 1.4(b) shows a human • In a strong magnetic field, the nucleus of the hydrogen atom—a
kidney. proton—tends to align itself with the field.
• The textured appearance of ultrasound images is called • Given the vast numbers of hydrogen atoms in the body, this
speckle, and it is a form of artifact. tendency results in a net magnetization of the body.
• Ultrasound imaging is described in detail in Chapters 10 and 11. • It is then possible to selectively excite regions within the body,
causing groups of these ‘‘little magnets’’ to tip away from the
magnetic field direction.

• As the protons return back into alignment with the field, they • The most general categories of operation are the following:
wobble like children’s tops. • Standard MRI, which includes a whole host of pulse sequences
• Because protons are charged particles, this precession (time-series of different excitation pulses)
generates an RF electromagnetic signature, which can be • Echo-planar imaging (EPI), which utilizes specialized methods
sensed with an antenna. to generate images in real time
• There are many modes in which an MR scanner can operate; • Magnetic resonance spectroscopic imaging (MRS), which
these scanners are incredibly flexible imaging devices. records images of other nuclei besides that of the hydrogen
atom

• Functional MRI (fMRI), which uses oxygenation-sensitive pulse

sequences to image blood oxygenation in the brain, which can
be related to brain activity
• Diffusion MRI (dMRI), which images the degree and orientation
of molecular diffusion in tissue

(a) An MR scanner and

(b) an MR image of a
human knee.

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Multimodality Imaging

• We mainly discuss standard MRI, and brief descriptions of fMRI • Different medical imaging modalities reveal different properties
and dMRI are also provided. of the human body.
• An MR scanner is shown in Figure 1.5(a). Surrounding the tube • As a result, it is often useful to obtain diagnostic images of a
in the center of the picture, within the housing, is a 3 tesla single patient and medical condition using multiple modalities.
superconducting magnet. • For example, one might look at bones using CT and soft tissues
• The field is very uniform within the bore, which is required for using MRI, or one might examine brain structure using MRI and
geometrically accurate imaging. The MR image in Figure 1.5(b) brain function using PET.
shows a cross section of a human knee.
• MRI is discussed in detail in Chapters 12 and 13.

Summary

• Combining CT and PET is particularly useful because PET • In practice, radiologists look for specific patterns in medical
provides functional information that complements the structural images.
information provided by CT and also because the CT data can • These patterns depend on both the patient and the imaging
be directly used to improve the reconstructed PET images. modality.
• Because of this, virtually all modern PET systems are sold as • It is the job of the engineers and scientists who develop medical
PET/CT systems that combine the two modalities within a single imaging systems to produce images that are as accurate and
platform. useful as possible; these systems depend on the physics of
each modality.

Key Concepts
‫الحمد هلل الرب العلمين‬
1. Medical imaging relies on non-invasive techniques to image body ‫والسلم عليكم ورحمة هللا وبركاته‬
structures and function.
2. Each technique or method is a different imaging modality.
3. The main imaging modalities are projection radiography, computed Thank you for your attention!
tomography, nuclear medicine, ultrasound imaging, and magnetic
resonance imaging.
4. The signal of interest is defined by the modality and specific
imaging parameters.
5. Radiologists are trained to look for specific patterns, defined by the
modality, specific imaging parameters, and differences in the Engineering is essentially a problem-solving.
expected signal in health and disease.

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