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Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of
medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to rev ...
, a fluoroscope () allows a physician to see the internal
structure A structure is an arrangement and organization of interrelated elements in a material object or system, or the object or system so organized. Material structures include man-made objects such as buildings and machines and natural objects such as ...
and function of a patient, so that the pumping action of the heart or the motion of
swallowing Swallowing, sometimes called deglutition in scientific contexts, is the process in the human or animal body that allows for a substance to pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. Swallowing i ...
, for example, can be watched. This is useful for both diagnosis and therapy and occurs in general radiology,
interventional radiology Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs bo ...
, and image-guided
surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
. In its simplest form, a fluoroscope consists of an X-ray source and a fluorescent screen, between which a patient is placed. However, since the 1950s most fluoroscopes have included X-ray image intensifiers and cameras as well, to improve the image's visibility and make it available on a remote display screen. For many decades, fluoroscopy tended to produce live pictures that were not recorded, but since the 1960s, as technology improved, recording and playback became the norm. Fluoroscopy is similar to radiography and X-ray computed tomography (X-ray CT) in that it generates images using X-rays. The original difference was that radiography fixed still images on
film A film also called a movie, motion picture, moving picture, picture, photoplay or (slang) flick is a work of visual art that simulates experiences and otherwise communicates ideas, stories, perceptions, feelings, beauty, or atmosphere ...
whereas fluoroscopy provided live moving pictures that were not stored. However, today radiography, CT, and fluoroscopy are all digital imaging modes with
image analysis Image analysis or imagery analysis is the extraction of meaningful information from images; mainly from digital images by means of digital image processing techniques. Image analysis tasks can be as simple as reading bar coded tags or as sophi ...
software and data storage and retrieval.


Mechanism of action

Although visible light can be seen by the naked eye (and thus forms images that people can look at), it does not penetrate most objects (only translucent ones). In contrast, X-rays can penetrate a wider variety of objects (such as the human body), but they are invisible to the naked eye. To take advantage of the penetration for image-forming purposes, one must somehow convert the X-rays'
intensity Intensity may refer to: In colloquial use *Strength (disambiguation) *Amplitude * Level (disambiguation) * Magnitude (disambiguation) In physical sciences Physics *Intensity (physics), power per unit area (W/m2) *Field strength of electric, ma ...
variations (which correspond to material contrast and thus image contrast) into a form that is visible. Classic film-based radiography achieves this by the variable chemical changes that the X-rays induce in the
film A film also called a movie, motion picture, moving picture, picture, photoplay or (slang) flick is a work of visual art that simulates experiences and otherwise communicates ideas, stories, perceptions, feelings, beauty, or atmosphere ...
, and classic fluoroscopy achieves it by fluorescence, in which certain materials convert X-ray energy (or other parts of the spectrum) into visible light. This use of fluorescent materials to make a viewing scope is how fluoroscopy got its name. As the X-rays pass through the patient, they are attenuated by varying amounts as they pass through or reflect off the different tissues of the body, casting an X-ray shadow of the radiopaque tissues (such as bone tissue) on the fluorescent screen. Images on the screen are produced as the unattenuated or mildly attenuated X-rays from
radiolucent Radiodensity (or radiopacity) is opacity to the radio wave and X-ray portion of the electromagnetic spectrum: that is, the relative inability of those kinds of electromagnetic radiation to pass through a particular material. Radiolucency or hypod ...
tissues interact with atoms in the screen through the photoelectric effect, giving their energy to the electrons. While much of the energy given to the electrons is dissipated as heat, a fraction of it is given off as visible light. Early radiologists would adapt their eyes to view the dim fluoroscopic images by sitting in darkened rooms, or by wearing
red adaptation goggles Dark adaptor goggles, also called red adaptation goggles, are used in the field of meteorology and astronomy for adapting the eyes to the dark prior to an observation at night. They also aid with the identification of clouds during bright sunshi ...
. After the development of X-ray image intensifiers, the images were bright enough to see without goggles under normal ambient light. Nowadays, in all forms of digital X-ray imaging (radiography, fluoroscopy, and CT) the conversion of X-ray energy into visible light can be achieved by the same types of electronic sensors, such as
flat panel detector Flat-panel detectors are a class of solid-state x-ray digital radiography devices similar in principle to the image sensors used in digital photography and video. They are used in both projectional radiography and as an alternative to x-ray image ...
s, which convert the X-ray energy into electrical signals: small bursts of
electric current An electric current is a stream of charged particles, such as electrons or ions, moving through an electrical conductor or space. It is measured as the net rate of flow of electric charge through a surface or into a control volume. The moving pa ...
that convey information that a computer can analyze, store, and output as images. As fluorescence is a special case of luminescence, digital X-ray imaging is conceptually similar to digital gamma ray imaging ( scintigraphy,
SPECT Single-photon emission computed tomography (SPECT, or less commonly, SPET) is a nuclear medicine tomographic imaging technique using gamma rays. It is very similar to conventional nuclear medicine planar imaging using a gamma camera (that is, ...
, and PET) in that in both of these imaging mode families, the information conveyed by the variable attenuation of invisible electromagnetic radiation as it passes through tissues with various radiodensities is converted by an electronic sensor into an electric signal that is processed by a computer and output as a visible-light image.


Medical use

Fluoroscopy has become an important tool in medical imaging to render moving pictures during a surgery or any other procedure.


Surgical fluoroscopy

Fluoroscopy is used in various types of surgical procedure, such as orthopaedic surgery and podiatric surgery. In both of those, it is used to guide fracture reduction and in use in certain procedures that have extensive hardware.


Urology

In urology, fluoroscopy is used in retrograde pyelography and micturating cystourethrography to detect various abnormalities related to the urinary system.


Cardiology

In cardiology, fluoroscopy is used for diagnostic angiography,
percutaneous coronary intervention Percutaneous coronary intervention (PCI) is a non-surgical procedure used to treat narrowing of the coronary arteries of the heart found in coronary artery disease. The process involves combining coronary angioplasty with stenting, which is the ...
s, ( pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization devices).


Gastrointestinal fluoroscopy

Fluoroscopy can be used to examine the digestive system using a substance that is opaque to X-rays (usually
barium sulfate Barium sulfate (or sulphate) is the inorganic compound with the chemical formula Ba SO4. It is a white crystalline solid that is odorless and insoluble in water. It occurs as the mineral barite, which is the main commercial source of barium an ...
or
gastrografin Diatrizoate, also known as amidotrizoate, is a contrast agent used during X-ray imaging. This includes visualizing veins, the urinary system, spleen, and joints, as well as computer tomography (CT scan). It is given by mouth, injection into a vei ...
), which is introduced into the digestive system either by swallowing or as an enema. This is normally as part of a double-contrast technique, using positive and negative contrast. Barium sulfate coats the walls of the digestive tract (positive contrast), which allows the shape of the digestive tract to be outlined as white or clear on an X-ray. Air may then be introduced (negative contrast), which looks black on the film. The barium meal is an example of a contrast agent swallowed to examine the upper digestive tract. While soluble barium compounds are very toxic, the insoluble barium sulfate is nontoxic because its low solubility prevents the body from absorbing it. Investigations of the
gastrointestinal tract The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organ (biology), organs of the digestive syste ...
include barium enemas, defecating proctograms, barium meals and
swallows The swallows, martins, and saw-wings, or Hirundinidae, are a family of passerine songbirds found around the world on all continents, including occasionally in Antarctica. Highly adapted to aerial feeding, they have a distinctive appearance. The ...
, and enteroclysis.


Other medical uses

* Liver biopsy is performed under fluoroscopic guidance at many centers. * Angiography of the leg, heart, and cerebral vessels. * Placement of a peripherally inserted central catheter * Placement of a weighted feeding tube (e.g. Dobhoff) into the duodenum after previous attempts without fluoroscopy have failed * Discography, an invasive diagnostic procedure for evaluation for
intervertebral disc An intervertebral disc (or intervertebral fibrocartilage) lies between adjacent vertebrae in the vertebral column. Each disc forms a fibrocartilaginous joint (a symphysis), to allow slight movement of the vertebrae, to act as a ligament to hold t ...
pathology. * In lumbar puncture, fluoroscopy helps to guide where the needles of the spinal tap can go, and may reduce the number of attempts required for a successful lumbar puncture.


Other uses

Fluoroscopy is also used in airport security scanners to check for hidden weapons or bombs. These machines use lower doses of radiation than medical fluoroscopy. The reason for higher doses in medical applications is that they are more demanding about tissue contrast, and for the same reason they sometimes require contrast media.


History


Early era

Fluoroscopy's origins and radiography's origins can both be traced back to 8 November 1895, when
Wilhelm Röntgen Wilhelm Conrad Röntgen (; ; 27 March 184510 February 1923) was a German mechanical engineer and physicist, who, on 8 November 1895, produced and detected electromagnetic radiation in a wavelength range known as X-rays or Röntgen rays, an achiev ...
, or in English script Roentgen, noticed a
barium Barium is a chemical element with the symbol Ba and atomic number 56. It is the fifth element in group 2 and is a soft, silvery alkaline earth metal. Because of its high chemical reactivity, barium is never found in nature as a free element. Th ...
platinocyanide screen fluorescing as a result of being exposed to what he would later call X-rays (algebraic x variable signifying "unknown"). Within months of this discovery, the first crude fluoroscopes were created. These experimental fluoroscopes were simply thin cardboard screens that had been coated on the inside with a layer of fluorescent metal salt, attached to a funnel-shaped cardboard eyeshade which excluded room light with a viewing eyepiece which the user held up to his eye. The fluoroscopic image obtained in this way was quite faint. Even when finally improved and commercially introduced for diagnostic imaging, the limited light produced from the fluorescent screens of the earliest commercial scopes necessitated that a radiologist sit for a period in the darkened room where the imaging procedure was to be performed, to first accustom his eyes to increase their sensitivity to perceive the faint image. The placement of the radiologist behind the screen also resulted in significant dosing of the radiologist. In the late 1890s, Thomas Edison began investigating materials for ability to fluoresce when X-rayed, and by the turn of the century he had invented a fluoroscope with sufficient image intensity to be
commercialized Trade involves the transfer of goods and services from one person or entity to another, often in exchange for money. Economists refer to a system or network that allows trade as a market. An early form of trade, barter, saw the direct exchan ...
. Edison had quickly discovered that calcium tungstate screens produced brighter images. Edison, however, abandoned his researches in 1903 because of the health hazards that accompanied use of these early devices. Clarence Dally, a glass blower of lab equipment and tubes at Edison's laboratory was repeatedly exposed, developing radiation poisoning, later dying from an aggressive cancer. Edison himself damaged an eye in testing these early fluoroscopes. During this infant commercial development, many incorrectly predicted that the moving images of fluoroscopy would completely replace roentgenographs (radiographic still image films), but the then superior diagnostic quality of the roentgenograph and their already alluded-to safety enhancement of lower
radiation dose Ionizing radiation (or ionising radiation), including nuclear radiation, consists of subatomic particles or electromagnetic waves that have sufficient energy to ionize atoms or molecules by detaching electrons from them. Some particles can travel ...
via shorter exposure prevented this from occurring. Another factor was that plain films inherently offered recording of the image in a simple and inexpensive way, whereas recording and playback of fluoroscopy remained a more complex and expensive proposition for decades to come ( discussed in detail below).
Red adaptation goggles Dark adaptor goggles, also called red adaptation goggles, are used in the field of meteorology and astronomy for adapting the eyes to the dark prior to an observation at night. They also aid with the identification of clouds during bright sunshi ...
were developed by
Wilhelm Trendelenburg Ernst Wilhelm Theodor Trendelenburg (16 July 1877 – 16 March 1946) was a German physiologist known for his work in physiological optics. He studied physiology at the University of Freiburg, receiving his doctorate from the University of Leipzig ...
in 1916 to address the problem of
dark adaptation Darkness, the direct opposite of lightness, is defined as a lack of illumination, an absence of visible light, or a surface that absorbs light, such as black or brown. Human vision is unable to distinguish colors in conditions of very low l ...
of the eyes, previously studied by
Antoine Beclere Antoine is a French given name (from the Latin ''Antonius'' meaning 'highly praise-worthy') that is a variant of Danton, Titouan, D'Anton and Antonin. The name is used in France, Switzerland, Belgium, Canada, West Greenland, Haiti, French Guiana ...
. The resulting red light from the goggles' filtration correctly sensitized the physician's eyes prior to the procedure, while still allowing him to receive enough light to function normally.


X-ray shoe fitting

More trivial uses of the technology emerged in the early 1920s, including a shoe-fitting fluoroscope that was used at shoe stores and department stores. Concerns regarding the impact of frequent or poorly controlled use were expressed in the late 1940s and 1950s. Issues raised by doctors and health professionals included the potential for burns to the skin, damage to bone, and abnormal development of the feet. These concerns lead to the development of new guidelines, regulations and ultimately the practice's end by the early 1960s. Shoe salesmen and industry representatives sometimes defended their use, claiming that there was no evidence of harm, and that their use prevented harm to the feet caused by poorly-fitted shoes. Fluoroscopy was discontinued in shoe-fitting because the radiation exposure risk outweighed the trivial benefit. Only important applications such as
health care Health care or healthcare is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health profe ...
, bodily safety,
food safety Food safety (or food hygiene) is used as a scientific method/discipline describing handling, preparation, and storage of food in ways that prevent food-borne illness. The occurrence of two or more cases of a similar illness resulting from t ...
,
nondestructive testing Nondestructive testing (NDT) is any of a wide group of analysis techniques used in science and technology industry to evaluate the properties of a material, component or system without causing damage. The terms nondestructive examination (NDE), n ...
, and scientific research meet the risk-benefit threshold for use.


Analog electronic era

Analog electronics revolutionized fluoroscopy. The development of the X-ray image intensifier by Westinghouse in the late 1940s in combination with closed circuit TV cameras of the 1950s allowed for brighter pictures and better radiation protection. The
red adaptation goggles Dark adaptor goggles, also called red adaptation goggles, are used in the field of meteorology and astronomy for adapting the eyes to the dark prior to an observation at night. They also aid with the identification of clouds during bright sunshi ...
became obsolete as image intensifiers allowed the light produced by the fluorescent screen to be amplified and made visible in a lighted room. The addition of the camera enabled viewing of the image on a monitor, allowing a radiologist to view the images in a separate room away from the risk of
radiation exposure Radiation is a moving form of energy, classified into ionizing and non-ionizing type. Ionizing radiation is further categorized into electromagnetic radiation (without matter) and particulate radiation (with matter). Electromagnetic radiation con ...
. The commercialization of video tape recorders beginning in 1956 allowed the TV images to be recorded and played back at will.


Digital electronic era

Digital electronics were applied to fluoroscopy beginning in the early 1960s, when
Frederick G. Weighart Frederick may refer to: People * Frederick (given name), the name Nobility Anhalt-Harzgerode *Frederick, Prince of Anhalt-Harzgerode (1613–1670) Austria * Frederick I, Duke of Austria (Babenberg), Duke of Austria from 1195 to 1198 * Frederi ...
, titled "X-Ray Apparatus Having Means for Supplying An Alternating Square Wave Voltage to the X-Ray Tube", granted to Weighart on October 4, 1964, showing its patent application date as May 10, 1963 and at lines 1-6 of its column 4, also, noting James F. McNulty's earlier filed co-pending application for an essential component of invention, see also this patent, titled "Fluoroscopy", referencing US Patent 3277302 to Weighart and detailing the fluoroscopy procedure for nondestructing testing. and James F. McNulty (1929-2014) at Automation Industries, Inc., then, in El Segundo, California produced on a fluoroscope the world's first image to be digitally generated in real-time, while developing a later commercialized portable apparatus for the onboard
nondestructive testing Nondestructive testing (NDT) is any of a wide group of analysis techniques used in science and technology industry to evaluate the properties of a material, component or system without causing damage. The terms nondestructive examination (NDE), n ...
of naval aircraft. Square wave signals were detected on a fluorescent screen to create the image. From the late 1980s onward, digital imaging technology was reintroduced to fluoroscopy after development of improved detector systems. Modern improvements in screen phosphors, digital image processing,
image analysis Image analysis or imagery analysis is the extraction of meaningful information from images; mainly from digital images by means of digital image processing techniques. Image analysis tasks can be as simple as reading bar coded tags or as sophi ...
, and
flat panel detectors Flat-panel detectors are a class of solid-state x-ray digital radiography devices similar in principle to the image sensors used in digital photography and video. They are used in both projectional radiography and as an alternative to x-ray imag ...
have allowed for increased image quality while minimizing the
radiation dose Ionizing radiation (or ionising radiation), including nuclear radiation, consists of subatomic particles or electromagnetic waves that have sufficient energy to ionize atoms or molecules by detaching electrons from them. Some particles can travel ...
to the patient. Modern fluoroscopes use caesium iodide (CsI) screens and produce noise-limited images, ensuring that the minimal radiation dose results while still obtaining images of acceptable quality.


Etymology

Many names exist in the medical literature for moving pictures taken with X-rays. They include fluoroscopy, fluorography, cinefluorography, photofluorography, fluororadiography, kymography (electrokymography, roentgenkymography), cineradiography (cine), videofluorography, and videofluoroscopy. Today, the word "fluoroscopy" is widely understood to be a hypernym of all the aforementioned terms, which explains why it is the most commonly used and why the others are declining in usage. The profusion of names is an idiomatic artifact of technological change, as follows: As soon as X-rays (and their application of seeing inside the body) were discovered in the 1890s, both looking and recording were pursued. Both live moving images and recorded still images were available from the beginning with simple equipment; thus, both "looking with a fluorescent screen" ( fluoro- + -scopy) and "recording/engraving with radiation" ( radio- +
-graphy The English suffix -graphy means a "field of study" or related to "writing" a book, and is an anglicization of the French ''-graphie'' inherited from the Latin ''-graphia'', which is a transliterated direct borrowing from Greek. Arts * Cartogr ...
) were immediately named with New Latin words—both words are attested since 1896. The quest for recorded moving images, though, was a more complex challenge. In the 1890s, moving pictures of any kind (whether taken with visible light or with invisible radiation) were
emerging technologies Emerging technologies are technologies whose development, practical applications, or both are still largely unrealized. These technologies are generally new but also include older technologies finding new applications. Emerging technologies ar ...
. Because the word " photography" (literally "recording/engraving with light") was long since established as connoting a still-image medium, the word " cinematography" (literally "recording/engraving movement") was coined for the new medium of visible-light moving pictures. Soon, several new words were coined for achieving moving radiographic pictures. This was often done either by filming a simple fluoroscopic screen with a movie camera (variously called fluorography, cinefluorography, photofluorography, or fluororadiography) or by taking serial radiographs rapidly to serve as the frames in a movie (cineradiography). Either way, the resulting film reel could be displayed by a movie projector. Another group of techniques included various kinds of kymography, whose common theme was capturing recordings in a series of moments, with a concept similar to movie film, although not necessarily with movie-type playback; rather, the sequential images would be compared frame by frame (a distinction comparable to tile mode versus cine mode in today's CT terminology). Thus, electrokymography and roentgenkymography were among the early ways to record images from a simple fluoroscopic screen. Television also was under early development during these decades (1890s–1920s), but even after commercial TV began widespread adoption after World War II, it remained a live-only medium for a time. In the mid-1950s, a commercialized ability to capture the moving pictures of television onto
magnetic tape Magnetic tape is a medium for magnetic storage made of a thin, magnetizable coating on a long, narrow strip of plastic film. It was developed in Germany in 1928, based on the earlier magnetic wire recording from Denmark. Devices that use magne ...
(with a video tape recorder) was developed. This soon led to the addition of the " video-" prefix to the words fluorography and fluoroscopy, with the words videofluorography and videofluoroscopy attested since 1960. In the 1970s, video tape moved from TV studios and medical imaging into the consumer market with home video via VHS and
Betamax Betamax (also known as Beta, as in its logo) is a consumer-level analog recording and cassette format of magnetic tape for video, commonly known as a video cassette recorder. It was developed by Sony and was released in Japan on May 10, 1975, ...
, and those formats were also incorporated into medical video equipment. Thus, over time the cameras and recording media for fluoroscopic imaging have progressed: The original kind of fluoroscopy, and the common kind for its first half century of existence, simply used none, because for most diagnosis and treatment, they were not essential. For those investigations that needed to be transmitted or recorded (such as for training or research), movie cameras using film (such as
16 mm film 16 mm film is a historically popular and economical gauge of film. 16 mm refers to the width of the film (about inch); other common film gauges include 8 and 35 mm. It is generally used for non-theatrical (e.g., industrial, educ ...
) were the medium. In the 1950s, analog electronic video cameras (at first only producing live output, but later using video tape recorders) appeared. Since the 1990s, digital video cameras,
flat panel detector Flat-panel detectors are a class of solid-state x-ray digital radiography devices similar in principle to the image sensors used in digital photography and video. They are used in both projectional radiography and as an alternative to x-ray image ...
s, and storage of data to local servers or (more recently) secure cloud servers have been used. Late-model fluoroscopes all use digital image processing and
image analysis Image analysis or imagery analysis is the extraction of meaningful information from images; mainly from digital images by means of digital image processing techniques. Image analysis tasks can be as simple as reading bar coded tags or as sophi ...
software, which not only helps to produce optimal image clarity and contrast, but also allows that result with a minimal radiation dose (because signal processing can take tiny inputs from low radiation doses and amplify them while to some extent also differentiating signal from noise). Whereas the word "cine" () in general usage refers to cinema (that is, a movie) or to certain film formats ( cine film) for recording such a movie, in medical usage it refers to cineradiography or, in recent decades, to any digital imaging mode that produces cine-like moving images (for example, newer CT and MRI systems can put out to either cine mode or tile mode). Cineradiography records 30-frame/second fluoroscopic images of internal organs such as the heart taken during injection of contrast dye to better visualize regions of
stenosis A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture'' ...
, or to record motility in the body's gastrointestinal tract. The predigital technology is being replaced with digital imaging systems. Some of these decrease the frame rate, but also decrease the absorbed dose of radiation to the patient. As they improve, frame rates will likely increase. Today, owing to technological convergence, the word "fluoroscopy" is widely understood to be a hypernym of all the earlier names for moving pictures taken with X-rays, both live and recorded. Also owing to technological convergence, radiography, CT, and fluoroscopy are now all digital imaging modes using X-rays with image-analysis software and easy data storage and retrieval. Just as movies, TV, and web videos are to a substantive extent no longer separate technologies, but only variations on common underlying digital themes, so, too, are the X-ray imaging modes, and indeed, the term "X-ray imaging" is the ultimate hypernym that unites all of them, even subsuming both fluoroscopy and four-dimensional CT (4DCT), which is the newest form of moving pictures taken with X-rays. Many decades may pass before the earlier hyponyms fall into disuse, not the least because the day when 4D CT displaces all earlier forms of moving X-ray imaging may yet be distant.


Adverse effects

The use of X-rays, a form of
ionizing radiation Ionizing radiation (or ionising radiation), including nuclear radiation, consists of subatomic particles or electromagnetic waves that have sufficient energy to ionize atoms or molecules by detaching electrons from them. Some particles can travel ...
, requires the potential risks from a procedure to be carefully balanced with the benefits of the procedure to the patient. Because the patient must be exposed to a continuous source of X-rays instead of a momentary pulse, a fluoroscopy procedure generally subjects a patient to a higher
absorbed dose Absorbed dose is a dose quantity which is the measure of the energy deposited in matter by ionizing radiation per unit mass. Absorbed dose is used in the calculation of dose uptake in living tissue in both radiation protection (reduction of harmf ...
of radiation than an ordinary (still) radiograph. Only important applications such as
health care Health care or healthcare is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health profe ...
, bodily safety,
food safety Food safety (or food hygiene) is used as a scientific method/discipline describing handling, preparation, and storage of food in ways that prevent food-borne illness. The occurrence of two or more cases of a similar illness resulting from t ...
,
nondestructive testing Nondestructive testing (NDT) is any of a wide group of analysis techniques used in science and technology industry to evaluate the properties of a material, component or system without causing damage. The terms nondestructive examination (NDE), n ...
, and scientific research meet the risk-benefit threshold for use. In the first half of the 20th century, shoe-fitting fluoroscopes were used in shoe stores, but their use was discontinued because it is no longer considered acceptable to use radiation exposure, however small the dose, for nonessential purposes. Much research has been directed toward reducing radiation exposure, and recent advances in fluoroscopy technology such as digital image processing and flat panel detectors, have resulted in much lower radiation doses than former procedures. Because fluoroscopy involves the use of X-rays, a form of
ionizing radiation Ionizing radiation (or ionising radiation), including nuclear radiation, consists of subatomic particles or electromagnetic waves that have sufficient energy to ionize atoms or molecules by detaching electrons from them. Some particles can travel ...
, fluoroscopic procedures pose a potential for increasing the patient's risk of radiation-induced cancer,in addition to the cancer risk and other stochastic radiation effects, deterministic radiation effects have also been observed ranging from mild erythema, equivalent of a sun burn, to more serious burns. Radiation doses to the patient depend greatly both on the size of the patient and length of the procedure, with typical skin dose rates quoted as 20–50
mGy The gray (symbol: Gy) is the unit of ionizing radiation dose in the International System of Units (SI), defined as the absorption of one joule of radiation energy per kilogram of matter. It is used as a unit of the radiation quantity absorbed do ...
/min. Exposure times vary depending on the procedure being performed, ranging from minutes to hours. A study of radiation-induced skin injuries was performed in 1994 by the U.S. Food and Drug Administration (FDA) followed by an advisory to minimize further fluoroscopy-induced injuries. The problem of radiation injuries due to fluoroscopy has been further addressed in review articles in 2000 and 2010. While deterministic radiation effects are a possibility, radiation burns are not typical of standard fluoroscopic procedures. Most procedures sufficiently long in duration to produce radiation burns are part of necessary life-saving operations. X-ray image intensifiers generally have radiation-reducing systems such as pulsed rather than constant radiation, along with "last image hold", which "freezes" the screen and makes it available for examination without exposing the patient to unnecessary radiation. Image intensifiers have been introduced that increase the brightness of the screen, so that the patient can be exposed to a lower dose of X-rays. Whilst this reduces the risk of ionisation occurring, it does not remove it entirely.


Equipment


X-ray image intensifiers

The invention of X-ray image intensifiers in the 1950s allowed the image on the screen to be visible under normal lighting conditions, and provided the option of recording the images with a conventional camera. Subsequent improvements included the coupling of, at first, video cameras, and later, digital cameras using image sensors such as charge-coupled devices or
active pixel sensor An active-pixel sensor (APS) is an image sensor where each pixel sensor unit cell has a photodetector (typically a pinned photodiode) and one or more active transistors. In a metal–oxide–semiconductor (MOS) active-pixel sensor, MOS field-effec ...
s to permit recording of moving images and electronic storage of still images. Modern image intensifiers no longer use a separate fluorescent screen. Instead, a caesium iodide phosphor is deposited directly on the photocathode of the intensifier tube. On a typical general-purpose system, the output image is approximately 105 times brighter than the input image. This brightness gain comprises a flux gain (amplification of photon number) and minification gain (concentration of photons from a large input screen onto a small output screen) each of about 100. This level of gain is sufficient that quantum noise, due to the limited number of X-ray photons, is a significant factor limiting image quality. Within the XRII, five mini components make up this intensifier, which are: * The glass envelope helps maintain the tube vacuum to allow control of the electron flow, but it has no actual functional part in the image formation. * Input phosphor, when the X-rays interact with this piece, its energy is converted into a burst of visible light photons as they occur like this on the intensifying screen/monitor. * The photocathode is a thin metal layer, that is usually composed of caesium and antimony compounds that respond to stimulation by the light with the emission of the electron. * The electrostatic focusing lenses are located along the length of the tube and are responsible for the focusing of the electrons across the tube from the input to the output phosphor. * The output phosphor is usually made up of cadmium sulfide crystals and is what records the arrival of the photoelectrons and normally results in 50-70 times gain. Image intensifiers are available with input diameters up to 45 cm, and a resolution around two to three line pairs/mm.


Flat-panel detectors

The introduction of flat-panel detectors allows for the replacement of the image intensifier in fluoroscope design. Flat-panel detectors offer increased sensitivity to X-rays, so have the potential to reduce patient radiation dose. Temporal resolution is also improved over image intensifiers, reducing motion blurring. Contrast ratio is also improved over image intensifiers; flat-panel detectors are linear over a very wide latitude, whereas image intensifiers have a maximum contrast ratio of about 35:1. Spatial resolution is roughly equal, although an image intensifier operating in magnification mode may be slightly better than a flat panel. Flat-panel detectors are considerably more expensive to purchase and repair than image intensifiers, so their use adoption is primarily in specialties that require high-speed imaging, e.g.,
vascular imaging Blood vessels are the structures of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away from t ...
and
cardiac catheterization Cardiac catheterization (heart cath) is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes. A common example of cardiac catheterization is coronary catheterization that ...
.


Contrast agents

A number of substances have been used as radiocontrast agents, including silver, bismuth,
caesium Caesium (IUPAC spelling) (or cesium in American English) is a chemical element with the symbol Cs and atomic number 55. It is a soft, silvery-golden alkali metal with a melting point of , which makes it one of only five elemental metals that a ...
, thorium, tin, zirconium, tantalum, tungsten, and
lanthanide The lanthanide () or lanthanoid () series of chemical elements comprises the 15 metallic chemical elements with atomic numbers 57–71, from lanthanum through lutetium. These elements, along with the chemically similar elements scandium and yttr ...
compounds. The use of
thoria ''Thoria'' is a genus of shield bugs in the tribe Podopini Podopinae, known as turtle bugs, are a subfamily of the insect family Pentatomidae. The type genus is '' Podops''. Tribes and Genera ''BioLib'' lists: Brachycerocorini Auth. Davidova ...
(thorium dioxide) as an agent was rapidly stopped, as thorium causes liver cancer. Most modern injected radiographic positive contrast media are iodine-based. Iodinated contrast comes in two forms - ionic and nonionic compounds. Nonionic contrast is significantly more expensive than ionic (about three to five times the cost), but nonionic contrast tends to be safer for the patient, causing fewer allergic reactions and uncomfortable side effects such as hot sensations or flushing. Most imaging centers now use nonionic contrast exclusively, finding that the benefits to patients outweigh the expense. Negative radiographic contrast agents are air and carbon dioxide (CO2). The latter is easily absorbed by the body and causes less spasm. It can also be injected into the blood, where air absolutely cannot due to the risk of an
air embolism An air embolism, also known as a gas embolism, is a blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system. Air can be introduced into the circulation during surgical procedures, lung over-expansion i ...
.


Imaging concerns

In addition to spatial blurring factors that plague all X-ray imaging devices, caused by such things as
Lubberts effect The Lubberts effect is the non-uniform response of an imaging system to X-rays that are absorbed at different depths within the input phosphor. It indicates an input phosphor depth-dependent response of the imaging system. It is named for G. Lubbe ...
, K-fluorescence reabsorption, and electron range, fluoroscopic systems also experience temporal blurring due to system latency. This temporal blurring has the effect of averaging frames together. While this helps reduce noise in images with stationary objects, it creates motion blurring for moving objects. Temporal blurring also complicates measurements of system performance for fluoroscopic systems.


References


External links


Fluoroscopy
FDA Radiological Health Program *

at Straight Dope, 27 November 1987
Fluoroscopy video in the medical field

Fluoroscopy video in the Nondestructive Testing field
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