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Quality assurance of computed and digital

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Article in Radiation Protection Dosimetry · April 2008

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 Radiation Protection Dosimetry Advance Access published March 4, 2008

Radiation Protection Dosimetry (2008), pp. 1–5 doi:10.1093/rpd/ncn047

QUALITY ASSURANCE OF COMPUTED AND DIGITAL

RADIOGRAPHY SYSTEMS
C. Walsh1,2, *, D. Gorman1, P. Byrne1, A. Larkin1, A. Dowling1 and J. F. Malone1
1
Haughton Institute, Dublin 8 & The Adelaide and Meath Hospital incorporating the National Children’s
Hospital, Dublin,
2
Haughton Institute & St. James’s Hospital, Dublin 8, Ireland

Computed radiography (CR) and digital radiography (DR) are replacing traditional film screen radiography as hospitals move
towards digital imaging and picture archiving and communication systems (PACS). Both IPEM and KCARE have recently
published quality assurance and acceptance testing guidelines for DR. In this paper, the performance of a range of CR and
DR systems is compared. Six different manufacturers are included. Particular attention is paid to the performance of the
systems under automatic exposure control (AEC). The patient is simulated using a range of thicknesses of tissue equivalent
material. Image quality assessment was based on detector assessment protocols and includes pixel value measures as well as
subjective assessment using Leeds Test Objects. The protocols for detector assessment cover a broad range of tests and in
general detectors (whether DR or CR) performed satisfactorily. The chief limitation in performing these tests was that not all
systems provided ready access to pixel values. Subjective tests include the use of the Leeds TO20. As part of this work,
suggested reference values are provided to calculate the TO20 image quality factor. One consequence of moving from film
screen to digital technologies is that the dynamic range of digital detectors is much wider, and increased exposures are no
longer evident from changes in image quality. As such, AEC is a key parameter for CR and DR. Dose was measured using a
standard phantom as a basic means of comparing systems. In order to assess the AEC performance, exit doses were also
measured while varying phantom thickness. Signal-to-noise ratios (SNRs) were calculated on a number of systems where pixel
values were available. SNR was affected by the selection of acquisition protocol. Comparisons between different technologies
and collation of data will help refine acceptance thresholds and contribute to optimising dose and image quality.

INTRODUCTION exposure dynamic range of such (DR and CR)

Film screen radiography is being replaced by com-
puted radiography (CR) and digital radiography
(DR). The digital images produced by these modalities
may be linked to PACS bringing in benefits of storage,
retrieval and image distribution, as well as image pro-
cessing to improve image quality. In the case of digital
detectors, improvements in detective quantum effi-
ciency may also be achieved with the potential of
reduced dose, image quality improvements or both.
Any new technology brings with it new challenges
in terms of its control and quality assurance (QA).
KCARE(1,2) have developed protocols for both CR
and DR receptors; IPEM(3) have expanded their X-
ray system tests to encompass digital technologies;
AAPM have also published a protocol for CR
QA(4). In general, the generators and X-ray tubes in
the radiographic systems used in CR and DR
remain the same as their film screen system counter-
parts and QA of the X-ray tube and generators in
digital systems follows the standard methods(3).
However, when automatic exposure control (AEC) is
selected, the X-ray output is linked (directly or
indirectly) to the detector performance and this
must be considered. The Medicines and Healthcare
products Regulatory Agency in the UK (MHRA) in
advice published on the web notes: . . . ‘the wide
*Corresponding author: colin.walsh@amnch.ie
systems may have the disadvantage that, if the . . .
AEC . . . develops a fault or the output calibration
drifts, the dose increase/decrease may not be ident-
ified readily. Also, the wide exposure dynamic range
means there is significant potential for the initial set-
up of such systems not to be optimised(5).’
This paper reviews the performance of a range of
CR and DR systems. QA of monitors (soft copy)
performed as part of specific protocols is not
included in this work. However, monitor function
also forms a part of the QA results presented here,
where subjective evaluations of image quality are
made at a workstation/review monitor. Performance
under AEC is reviewed for DR systems.
MATERIAL AND METHODS
Image quality (IQ) assessments based on KCARE
protocol(1,2) were performed on 23 (Kodak, AGFA,
Fuji) CR systems, and 10 (Philips, Siemens, Mecall)
DR systems. All systems were less than 3 y in
service. Leeds Test Objects were used for some of
the IQ tests. Dose measurements were taken with
Radcal 6 and 60 cm3 dose chambers, which were
calibrated to international standards. For AEC
testing, PMMA was used to simulate a range of
patient thicknesses. High-purity aluminium and
copper filters were also used in some tests.

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 C. WALSH ET AL.
IQ tests were performed across the full range of
systems and followed the standard KCARE proto-
col. AEC test protocols are less well defined and a
range of approaches were tested on a subset of the
DR systems in an attempt to find an optimum
approach.
RESULTS AND DISCUSSION
Detector tests
In KCARE protocol (Rev 8)(1,2), the following tests
are listed under annual QC: dosimetry; dark noise;
detector dose indicator consistency; uniformity; blur-
ring and stitching artefacts; limiting spatial resol-
ution (in one quadrant at 458 only); threshold
contrast detail detectability (TCDD). The results of
these tests are described briefly below.
Dosimetry and dark noise
The tube-current exposure time (mA s) needed to
produce a range of output exposures is measured
and recorded. These values are used in later tests to
obtain the appropriate exposure for a given test (e.g.
evaluation of TCDD is based on a 4 mGy exposure).
The exposures are a function of tube and generator
performance.
Dark noise assesses the level of noise inherent in
the system. No peculiarities were noted in the tests
on any system: the results form a baseline for
ongoing monitoring of performance.
Dose detector index
Most CR and DR systems have some form of dose
detector index (DDI); essentially this is a numerical
value displayed with each exposure that correlates to
dose. The KCARE test assesses the consistency of
this value for a defined exposure. All systems were
within specification with coefficient of variation
(CV) ranging from 0 to 5.2%. In the systems where a
CV of 0% was measured, the resolution of the DDI
was found to be poor: in other words a considerable
variation in dose was required before the value incre-
mented or decremented. The 0% variation reflects
this poor sensitivity.
Uniformity
This test assesses the uniformity of the recorded
signal from a uniformly exposed (1 mm Cu at tube
head) detector. Full analysis requires access to pixel
values so that the standard deviation can be
measured in a given region of interest (ROI).
However, where pixel values are not available a sub-
jective assessment is possible by simply viewing the
image and looking for non-uniformities and
Page 2 of 5
imperfections. Viewing uniformity images is a crude
but useful test. In the case of one of the digital
systems assessed, the DR plate failed as it was
evident from visual inspection that one of the quad-
rants of the detector was displayed at a different
greyscale shading than the other three quadrants.
Subsequent examination by the supplier revealed a
detector fault (which had gone undetected in the
supplier’s commissioning tests). This test is also of
value in assessing CR plates. A batch of CR cas-
settes with intermittently faulty latches (which
allowed the plates to slip out of the cassette) was dis-
covered after speckling on uniformity images caused
by dust particles was observed.
Blurring and stitching artefacts
The system is tested for any localised distortion or
for stitching artefacts, by imaging mesh test objects
(e.g. Leeds Test Objects MS4). Blurring was not
observed in any of the systems tested. In digital
systems, the stitching artefact (essentially a cross
through the centre of the image, dividing the image
into four quadrants) was evident when the MS4
Leeds Test Objects were imaged, but the artefact was
processed out in uniformity images and clinical
images.
Limiting resolution and TCDD (Huttner and TO20)
Both tests objects are widely used in subjective
assessment of image quality; both suffer from con-
siderable inter- and intra-subjective variability(6,7).
The images may be viewed on machine review moni-
tors, as film prints, or on PACS stations. The assess-
ment takes in the whole imaging chain, as well as
some tube performance characteristics ( particularly
focal spot size). The Huttner provides a measure of
limiting spatial resolution and performance improves
with magnification. TO20 contains discs of varying
density for assessing threshold contrast. The discs
also vary in size, challenging the spatial resolution
of the system. TO20 has been identified by Marsh
et al.(8) as useful in overall image quality assessment.
Limiting spatial resolution ranged from 2.8 to 4 lp
mm21 and 3.15 to 5 lp mm21 for DR review moni-
tors and CR review stations, respectively. PACS
monitors showed 4–4.5 lp mm21 for images
acquired on DR, and 3.15 –5.6 lp mm21 for images
acquired on CR, with the higher values recorded for
the high-resolution CR plates. Limiting spatial resol-
ution of film prints taken from DR acquired images
ranged from 3.55 to 4.5 lp mm21. Limiting spatial
resolution should approach the Nyquist p limit; at 458
the Nyquist frequency is defined by 2/2p, where p
is the pixel pitch(1,2). For the DR systems, p ¼
0.143 mm and Nyquist frequency is 4.9 lp mm21,
only slightly higher than the results of the QA tests.
 QA OF CR AND DR SYSTEMS
Nyquist limit was 4.2 lp mm21 for standard sized
CR plates and 7.4 lp mm21 for the high-resolution
plates. Review monitors generally scored lower than
PACS monitors. Review monitors function simply to
ensure a proper image has been acquired and are
not intended as diagnostic monitors.
KCARE recommend calculating an image quality
factor (IQF) based on TCDD measures. The IQF is
based on work by Gallacher et al.(9). IQF is calcu-
lated according to Equation (1) and involves com-
parison between the system under test and a
reference set of results.
 
1X n
HT ðAi Þ Dref 0:5
IQF ¼ ð1Þ
n i¼1 HTref ðAi Þ D
where HT(A), threshold contrast detail index values
calculated from the image; Href T (A), threshold con-
trast detail index values calculated from a reference
image of a system known to be in good adjustment;
D, the dose to the image plate, Dref, the dose to the
image plate for the reference image; n, the number
of details in the test object.(1,2)
In the KCARE protocol, TO20 images are
acquired at 70 kVp, with 1 mm Cu in the beam and
the appropriate milliampere seconds to deliver
4 mGy. However, the look-up table for HT(A)
values is based on 75 kVp, with 1.5 mm Cu in the
beam(10). It was decided to keep the KCARE proto-
col for the tests. As use of the HT(A) values would
introduce an undefined error into the calculation,
the calculation was based on the number of targets
observed in each category and the quality factor was
denoted as IQF(b). All images are acquired and
analysed in the same way (including the reference
image) and IQF(b) is simply a comparison factor:
the more targets observed, the higher the score for
IQF(b) and the better the system’s contrast perform-
ance. A reference value by taking the median per-
formance of 12 CR and DR systems based on
reading film printouts has been obtained. The
median (and first quartile) values are shown in
Table 1. Taking each system individually and com-
paring it to the reference system (median value)
yielded the following results: for images acquired on
DR systems and displayed on PACS, IQF(b) ranged
from 0.9 to 1.22; IQF(b) of DR acquired images
Table 1. Suggested reference values for TO20 for each
target (a–m).
a b C d e F g h j K l M
Median 6 6 6 6 6 6 7 6 5 8 6 4
1st 5 5 5 6 5 4 6 6 5 7 6 4
Quartile
Page 3 of 5
printed to film ranged from 0.98 to 1.1. CR images
viewed on PACS had IQF(b)s ranging from 0.85 to
1.05; IQF(b) for CR images printed on film ranged
from 0.85 to 0.95. The images for these tests were
acquired and viewed with a standard clinical
protocol.
Automatic exposure control
A key performance indicator for AEC is receptor
dose: this dose should remain constant as patient
thickness varies. Measuring receptor dose in CR
systems is relatively straight forward as the measure-
ment chamber can easily be placed in the bucky tray.
In DR systems, the detector is often not readily
accessible. In this section, attention is restricted to
DR systems (where receptor dose is more difficult to
assess directly) and the problem of establishing an
optimum protocol for assessing AEC performance is
considered.
AEC tests for DR systems are summarised in
IPEM Report 91(2). However, most tests involve
recoding milliampere seconds or DDI (and thus do
not directly assess AEC performance) with only
limited guidelines offered to assess receptor dose
with varying phantom thickness. Expected values
are not suggested, and acceptance thresholds allow
wide variations from baseline for some of the tests.
A repeatability test is described using a standard
phantom and an exit dose test, which challenges
AEC performance with varying phantom thickness.
Repeatability
A 21 mm Al plate (supplied as standard with the
systems) was mounted at the tube head. The
measurement chamber was placed on the table or at
the face of the chest detector. SID (source to image
distance) was 150 cm for chest detectors and 110 cm
for table detectors. All exposures were taken at
70 kV and with AEC enabled. Six table detectors
and six chest detectors were assessed. Doses
measured at the table ranged from 4.0 to 5.5 mGy.
Mean dose was 4.8 mGy (+0.6). At the chest detec-
tor, doses ranged from 4.0 to 6.6 mGy. Mean dose
was 4.6 mGy (+1.0). This test does not challenge
AEC function, but provides a useful baseline
measure that can be compared directly to suppliers’
commissioning tests.
Exit dose with varying phantom thickness
Seven table detectors and five chest units were
assessed. Exposures were under AEC at 70 kV. The
grid was out. SID Table was 110 cm, SID chest was
150 cm. PMMA of thickness 5– 20 cm (varied in
5 cm steps) was placed in the beam. The PMMA
was raised 3–5 cm and the measurement chamber
 C. WALSH ET AL.
was placed on the detector side of the PMMA in
order to measure exit dose. With 15 cm PMMA in
the beam, average exit dose is 6.6 mGy at the table
and 6.0 mGy at the chest bucky. Expected receptor
dose for digital systems is 3–5 mGy (varies between
manufacturers). Exit dose will be slightly higher than
receptor dose because of attenuation of the table (or
covers for chest unit), the distance between the
measurement chamber and the image receptor and
differences in scatter. Exit doses are reasonably steady
for each system between 10 and 20 cm phantom
thickness. Doses are plotted and shown in Figure 1.
Signal-to-noise ratio
In addition to assessing individual parts of the
imaging chain (e.g. receptor performance), it is
useful to include some IQ measurements that assess
image quality after the image data has passed
through all stages involved in acquisition, processing
and display. Assessing quality of Huttner and TO20
images on PACS workstations involves a check on
the whole chain, but uses a subjective assessment
method. Measuring signal-to-noise ratio (SNR) of
test images, acquired at the X-ray system being
assessed, offers the possibility of a more objective IQ
test. If this is performed at the PACS workstations
the test encompasses the full imaging chain.
Our interest is reviewing the potential of employ-
ing a simple measure to estimate SNR that could be
incorporated into routine QA work. Software on
PACS systems allows easy access to pixel values. In
this experiment, SNR was calculated in a uniform
image as a simple ratio of mean pixel value and
standard deviation in a region of interest approxi-
mately 1/3 the size of the image. This technique is
similar to the one used in QA of digital
mammography(11).
Tests were restricted to two dual detector DR
systems. Images were acquired as above with
5– 20 cm PMMA in the beam. SNR values varied
from 27 to 39 across a range of clinical protocols
with PMMA thicknesses of 10–20 cm, but when a
machine QA protocol was selected SNR range
increased to 181–236 (Figure 2). The SNR increase
was due to a much lower standard deviation in the
ROI on the QA protocol. As the same phantom was
imaged with the same exposure parameters in each
case it appears likely that additional processing
(smoothing) is being performed on the images
acquired under the QA protocol. This result is also
of interest for the KCARE detector tests and
emphasises the need for caution in selecting acqui-
sition protocols that reflect clinical performance.

CONCLUSIONS
Most systems passed IQ detector tests; where failures
occurred, most were detected from visual inspection
Figure 1. Exit dose in mGy with varying PMMA thickness of uniformity images. The paper proposes reference
(cm). values for calculating IQF for CR and DR systems.

Figure 2. Variance in SNR with PMMA thickness (cm). Results 1– 4 were acquired with an abdomen protocol: 1 and 3
were acquired at table detectors; 2 and 4 were acquired at chest detectors. Results 5 and 6 were acquired at a table and
chest detector using a pre-programmed QA protocol.

Page 4 of 5
 QA OF CR AND DR SYSTEMS
The problem of assessing AEC is explored, and values
for exit dose are established for DR table and chest
detectors. Clinical protocols and particularly quality
protocols loaded on DR (or CR) systems may bring in
different processing features, complicating the task of
establishing simple, routine image quality tests, which
provide assurance of clinical function.
FUNDING
This work was conducted partially within the frame
of the European Commission 6th Framework
Programme SENTINEL Contract No FP6 – 012909.
REFERENCES
1. KCARE. Protocol for the QA of Computed
Radiography Systems, Commissioning and Annual QA
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2. KCARE. Protocol for the QA of Direct Digital
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protocols.htm.
3. IPEM Report 91. Recommended Standards for Routine
Performance Testing of Diagnostic X-ray Imaging
Systems, IPEM (2005).
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