Sarath Vijayan

Calculation of the entrance skin dose distribution for fluoroscopically guided interventions using a pencil beam backscatter model

Abstract. Radiation backscattered from the patient can contribute substantially to skin dose in fluoroscopically guided interventions (FGIs). The distribution of backscatter is not spatially uniform, and use of a single backscatter factor cannot provide an accurate determination of skin dose. This study evaluates a method to determine the backscatter spatial distribution through convolution of a backscatter-to-primary (BP) point spread function (PSFn). The PSFn is derived for a pencil beam using EGSnrc Monte Carlo software and is convolved with primary distributions using a dose-tracking system. The backscatter distribution calculated using the convolution method is validated with Monte Carlo-derived distributions for three different size “uniform” fields and with XR-QA2 Gafchromic film for nonuniform x-ray fields obtained using region-of-interest (ROI) attenuators and compensation filters, both with homogenous poly-methyl methacrylate and nonhomogenous head phantoms. The BP ratios inside uniform fields were calculated within ±2% of that determined using EGSnrc. For shaped fields, the BP ratio in the unattenuated ROI was calculated within ±3% of that measured with film; in the beam-attenuated periphery, agreement was within ±17%, due to the larger uncertainty of the dose-response curve of the film in the low-dose region. This backscatter PSFn convolution method is much faster than performing full-field Monte Carlo calculations and provides improved accuracy in skin dose distribution determination for FGI procedures.

SU-E-I-48: Noise Reduction with Over-Sampling for High Resolution Detectors Using a Spread Function Convolution Method

Purpose: A method to reduce noise resulting from the use of higher resolution x-ray detectors being developed to meet the demands of image guided vascular interventions is demonstrated. Methods: New direct detectors based on amorphous Se can have MTFs that remain high even at their Nyquist frequency. Since such detectors can be made with smaller pixels than may be required for even the high resolution requirements of many neurovascular applications, the resulting over-sampled images can be convolved with various functions to lower the noise. The effect on resolution can then be compared with a simple pixel binning. The general method proposed by Cunningham et al as the apodized-aperture pixel (AAP) design was compared with the Result for various simple 1D convolution spread functions with the effects on total noise and MTF compared to that of the binning case for a 25 μm aSe CMOS detector’s MTF published by the University of Waterloo group lead by KS Karim. Results: Assuming a white noise image, various convolution kernels resulted in similar reductions of total standard deviation. Detailed comparisons were made with the simple the 2x binning case. While reducing noise, the over-sampling convolution method using simple convolution low pass filters did not show advantage over 2x binning with regard to modifying the MTF; however, significant improvement was evidenced for the more complex sinc function used in the AAP design. Conclusion: As higher resolution detectors are being developed to meet the increasing demands for improved images to guide finer vascular interventions, use of super-sampled aSe detectors where resolution is maintained with reduced noise may well fill this requirement. Partial support from NIH Grant R01EB002873 and Toshiba Medical Systems Equipment Grant

SU-E-I-22: Dependence On Calibration Phantom and Field Area of the Conversion Factor Used to Calculate Skin Dose During Neuro-Interventional Fluoroscopic Procedures

PURPOSEnTo determine the appropriate calibration factor to use when calculating skin dose with our real-time dose-tracking system (DTS) during neuro-interventional fluoroscopic procedures by evaluating the difference in backscatter from different phantoms and as a function of entrance-skin field area.nnnMETHODSnWe developed a dose-tracking system to calculate and graphically display the cumulative skin-dose distribution in real time. To calibrate the DTS for neuro-interventional procedures, a phantom is needed that closely approximates the scattering properties of the head. We compared the x-ray backscatter from eight phantoms: 20-cm-thick solid water, 16-cm diameter water-filled container, 16-cm CTDI phantom, modified-ANSI head phantom, 20-cm-thick PMMA, Kyoto-Kagaku PBU- 50 head, Phantom-Labs SK-150 head, and RSD RS-240T head. The phantoms were placed on the patient table with the entrance surface at 15 cm tube-side from the isocenter of a Toshiba Infinix C-arm, and the entrance-skin exposure was measured with a calibrated 6-cc PTW ionization chamber. The measurement included primary radiation, backscatter from the phantom and forward scatter from the table and pad. The variation in entrance-skin exposure was also measured as a function of the skin-entrance area for a 30×30 cm by 20-cm-thick PMMA phantom and the SK-150 head phantom using four different added beam filters.nnnRESULTSnThe entranceskin exposure values measured for eight different phantoms differed by up to 12%, while the ratio of entrance exposure of all phantoms relative to solid water showed less than 3% variation with kVp. The change in entrance-skin exposure with entrance-skin area was found to differ for the SK-150 head compared to the 20-cm PMMA phantom and the variation with field area was dependent on the added beam filtration.nnnCONCLUSIONnTo accurately calculate skin dose for neuro-interventional procedures with the DTS, the phantom for calibration should be carefully chosen since different phantoms can contribute different backscatter for identical exposure parameters. Research supported in part by Toshiba Medical Systems and NIH Grants R43FD0158401, R44FD0158402 and R01EB002873.

Developing a database of 3D scattered radiation distributions for a C-arm fluoroscope as a function of exposure parameters and phantom

The purpose of this work is to develop a database of 3D scattered radiation dose-rate distributions to estimate the staff dose by location around a C-Arm fluoroscopic system in an interventional procedure room. The primary x-ray beam of a Toshiba Infinix fluoroscopy machine was modeled using EGSnrc Monte Carlo code and the scattered radiation distributions were calculated using 5 x 109 photons per simulation. These 3D distributions were determined over the volume of the room as a function of various parameters such as the beam kVp and beam filter, the size and shape of the field, the angulation of the Carm, and the phantom size and shape. Two phantom shapes were used in this study: cylindrical and superellipses. The results show that shape of the phantom will affect the dose-rate distribution at distances less than 100 cm, with a higher intensity for the super-ellipse. The scatter intensity per entrance air kerma is seen to be approximately proportional to field area and to increase with increasing kVp. The scatter changes proportionally with increases in primary entrance air kerma for factors such as pulse rate, mA and pulse width. This database will allow estimation of the scatter distribution in the procedure room and, when displayed to the staff during a procedure, may facilitate a reduction of occupational dose.

Investigation of organ dose variation with adult head size and pediatric age for neuro-interventional projections

The purpose of this study was to evaluate the effect of patient head size on radiation dose to radiosensitive organs, such as the eye lens, brain and spinal cord in fluoroscopically guided neuro-interventional procedures and CBCT scans of the head. The Toshiba Infinix C-Arm System was modeled in BEAMnrc/EGSnrc Monte-Carlo code and patient organ and effective doses were calculated in DOSxynrc/EGSnrc for CBCT and interventional procedures. X-ray projections from different angles, CBCT scans, and neuro-interventional procedures were simulated on a computational head phantom for the range of head sizes in the adult population and for different pediatric ages. The difference of left-eye lens dose between the mean head size and the mean ± 1 standard deviation (SD) ranges from 20% to 300% for projection angles of 0° to 90° RAO. The differences for other organs do not vary as much and is only about 10% for the brain. For a LCI-High CBCT protocol, the difference between mean and mean ± 1 SD head size is about 100% for lens dose and only 10% for mean and peak brain dose; the difference between 20 and 3 year-old mean head size is an increase of about 200% for the eye lens dose and only 30% for mean and peak brain dose. Dose for all organs increases with decreasing head size for the same reference point air kerma. These results will allow size-specific dose estimates to be made using software such as our dose tracking system (DTS).

Calculation of forward scatter dose distribution at the skin entrance from the patient table for fluoroscopically guided interventions using a pencil beam convolution kernel

The forward-scatter dose distribution generated by the patient table during fluoroscopic interventions and its contribution to the skin dose is studied. The forward-scatter dose distribution to skin generated by a water table-equivalent phantom and the patient table are calculated using EGSnrc Monte-Carlo and Gafchromic film as a function of x-ray field size and beam penetrability. Forward scatter point spread function’s (PSFn) were generated with EGSnrc from a 1×1 mm simulated primary pencil beam incident on the water model and patient table. The forward-scatter point spread function normalized to the primary is convolved over the primary-dose distribution to generate scatter-dose distributions. The utility of PSFn to calculate the entrance skin dose distribution using DTS (dose tracking system) software is investigated. The forward-scatter distribution calculations were performed for 2.32 mm, 3.10 mm, 3.84 mm and 4.24 mm Al HVL x-ray beams for 5×5 cm, 9×9 cm, 13.5×13.5 cm sized x-ray fields for water and 3.1 mm Al HVL x-ray beam for 16.5×16.5 cm field for the patient table. The skin dose is determined with DTS by convolution of the scatter dose PSFn’s and with Gafchromic film under PMMA “patient-simulating” blocks for uniform and for shaped x-ray fields. The normalized forward-scatter distribution determined using the convolution method for water table-equivalent phantom agreed with that calculated for the full field using EGSnrc within ±6%. The normalized forwardscatter dose distribution calculated for the patient table for a 16.5×16.5 cm FOV, agreed with that determined using film within ±2.4%. For the homogenous PMMA phantom, the skin dose using DTS was calculated within ±2 % of that measured with the film for both uniform and non-uniform x-ray fields. The convolution method provides improved accuracy over using a single forward-scatter value over the entire field and is a faster alternative to performing full-field Monte-Carlo calculations.

Monte Carlo investigation of backscatter point spread function for x-ray imaging examinations

X-ray imaging examinations, especially complex interventions, may result in relatively high doses to the patient’s skin inducing skin injuries. A method was developed to determine the skin-dose distribution for non-uniform x-ray beams by convolving the backscatter point-spread-function (PSF) with the primary-dose distribution to generate the backscatter distribution that, when added to the primary dose, gives the total-dose distribution. This technique was incorporated in the dose-tracking system (DTS), which provides a real-time color-coded 3D-mapping of skin dose during fluoroscopic procedures. The aim of this work is to investigate the variation of the backscatter PSF with different parameters. A backscatter PSF of a 1-mm x-ray beam was generated by EGSnrc Monte-Carlo code for different x-ray beam energies, different soft-tissue thickness above bone, different bone thickness and different entrance-beam angles, as well as for different locations on the SK-150 anthropomorphic head phantom. The results show a reduction of the peak scatter to primary dose ratio of 48% when X-ray beam voltage is increased from 40 keV to 120 keV. The backscatter dose was reduced when bone was beneath the soft tissue layer and this reduction increased with thinner soft tissue and thicker bone layers. The backscatter factor increased about 21% as the angle of incidence of the beam with the entrance surface decreased from 90° (perpendicular) to 30°. The backscatter PSF differed for different locations on the SK-150 phantom by up to 15%. The results of this study can be used to improve the accuracy of dose calculation when using PSF convolution in the DTS.

Organ and effective dose reduction for region-of-interest (ROI) CBCT and fluoroscopy

In some medical-imaging procedures using CBCT and fluoroscopy, it may be needed to visualize only the center of the field-of-view with optimal quality. To reduce the dose to the patient as well as enable increased contrast in the region of interest (ROI) during CBCT and fluoroscopy procedures, a 0.7 mm thick Cu ROI attenuator with a circular aperture 12% of the FOV was used. The aim of this study was to quantify the dose-reduction benefit of ROI imaging during a typical CBCT and interventional fluoroscopy procedures in the head and torso. The Toshiba Infinix C-Arm System was modeled in BEAMnrc/EGSnrc with and without the ROI attenuator. Patient organ and effective doses were calculated in DOSXYZnrc/EGSnrc Monte-Carlo software for CBCT and interventional procedures. We first compared the entrance dose with and without the ROI attenuator on a 20 cm thick solid-water block. Then we simulated a CBCT scan and an interventional fluoroscopy procedure on the head and torso with and without an ROI attenuator. The results showed that the entrance-surface dose reduction in the solid water is about 85.7% outside the ROI opening and 10.5% in the ROI opening. The results showed a reduction in most organ doses of 45%-70% and in effective dose of 46%-66% compared to the dose in a CBCT scan and in an interventional procedure without the ROI attenuator. This work provides evidence of substantial reduction of organ and effective doses when using an ROI attenuator during CBCT and fluoroscopic procedures.

Skin dose mapping for non-uniform x-ray fields using a backscatter point spread function

Beam shaping devices like ROI attenuators and compensation filters modulate the intensity distribution of the xray beam incident on the patient. This results in a spatial variation of skin dose due to the variation of primary radiation and also a variation in backscattered radiation from the patient. To determine the backscatter component, backscatter point spread functions (PSF) are generated using EGS Monte-Carlo software. For this study, PSF’s were determined by simulating a 1 mm beam incident on the lateral surface of an anthropomorphic head phantom and a 20 cm thick PMMA block phantom. The backscatter PSF’s for the head phantom and PMMA phantom are curve fit with a Lorentzian function after being normalized to the primary dose intensity (PSFn). PSFn is convolved with the primary dose distribution to generate the scatter dose distribution, which is added to the primary to obtain the total dose distribution. The backscatter convolution technique is incorporated in the dose tracking system (DTS), which tracks skin dose during fluoroscopic procedures and provides a color map of the dose distribution on a 3D patient graphic model. A convolution technique is developed for the backscatter dose determination for the nonuniformly spaced graphic-model surface vertices. A Gafchromic film validation was performed for shaped x-ray beams generated with an ROI attenuator and with two compensation filters inserted into the field. The total dose distribution calculated by the backscatter convolution technique closely agreed with that measured with the film.

Comparison of high resolution x-ray detectors with conventional FPDs using experimental MTFs and apodized aperture pixel design for reduced aliasing

Apodized Aperture Pixel (AAP) design, proposed by Ismailova et.al, is an alternative to the conventional pixel design. The advantages of AAP processing with a sinc filter in comparison with using other filters include non-degradation of MTF values and elimination of signal and noise aliasing, resulting in an increased performance at higher frequencies, approaching the Nyquist frequency. If high resolution small field-of-view (FOV) detectors with small pixels used during critical stages of Endovascular Image Guided Interventions (EIGIs) could also be extended to cover a full field-of-view typical of flat panel detectors (FPDs) and made to have larger effective pixels, then methods must be used to preserve the MTF over the frequency range up to the Nyquist frequency of the FPD while minimizing aliasing. In this work, we convolve the experimentally measured MTFs of an Microangiographic Fluoroscope (MAF) detector, (the MAF-CCD with 35μm pixels) and a High Resolution Fluoroscope (HRF) detector (HRF-CMOS50 with 49.5μm pixels) with the AAP filter and show the superiority of the results compared to MTFs resulting from moving average pixel binning and to the MTF of a standard FPD. The effect of using AAP is also shown in the spatial domain, when used to image an infinitely small point object. For detectors in neurovascular interventions, where high resolution is the priority during critical parts of the intervention, but full FOV with larger pixels are needed during less critical parts, AAP design provides an alternative to simple pixel binning while effectively eliminating signal and noise aliasing yet allowing the small FOV high resolution imaging to be maintained during critical parts of the EIGI.