Medical imaging

Medical imaging is the technique and process used to create images of the
human body (or parts and function thereof) for clinical purposes (medical
procedures seeking to reveal, diagnose or examine disease) or medical science
(including the study of normal anatomy and physiology).
As a discipline and in its widest sense, it is part of biological imaging and
incorporates radiology (in the wider sense), nuclear medicine,
investigative radiological sciences, endoscopy, (medical) thermography,
medical photography and microscopy (e.g. for human pathological
investigations).
Measurement and recording techniques which are not primarily designed to
produce images, such
as electroencephalography (EEG),magnetoencephalography (MEG), Electrocar
diography (EKG) and others, but which produce data susceptible to be
represented as maps (i.e. containing positional information), can be seen as
forms of medical imaging.
Contents
[hide]
• 1 Overview
• 2 Imaging technology
○ 2.1 Electron microscopy
○ 2.2 Radiographic
○ 2.3 Magnetic resonance imaging
(MRI)
○ 2.4 Nuclear medicine
○ 2.5 Photoacoustic imaging
○ 2.6 Breast Thermography
○ 2.7 Tomography
○ 2.8 Ultrasound
• 3 Medical imaging topics
○ 3.1 Creation of three-dimensional
images
○ 3.2 Non-diagnostic imaging
 ○ 3.3 Open source software
○ 3.4 Proprietary software
○ 3.5 Use in Pharmaceutical
Clinical Trials
• 4 See also
• 5 Further reading
○ 5.1 Academic resources
• 6 References
• 7 External links
[edit]Overview

In the clinical context, medical imaging is generally equated to radiology or

"clinical imaging" and the medical practitioner responsible for interpreting (and
sometimes acquiring) the images is a radiologist.
Diagnostic radiography designates the technical aspects of medical imaging and
in particular the acquisition of medical images. The radiographer or radiologic
technologist is usually responsible for acquiring medical images of diagnostic
quality, although some radiological interventions are performed by radiologists.
While radiology is an evaluation of anatomy, nuclear medicine provides
functional assessment.
As a field of scientific investigation, medical imaging constitutes a sub-
discipline of biomedical engineering, medical physics or medicinedepending on
the context: Research and development in the area of instrumentation, image
acquisition (e.g. radiography), modelling and quantification are usually the
preserve of biomedical engineering, medical physics and computer science;
Research into the application and interpretation of medical images is usually the
preserve of radiology and the medical sub-discipline relevant to medical
condition or area of medical science
(neuroscience, cardiology, psychiatry, psychology, etc) under investigation.
Many of the techniques developed for medical imaging also
have scientific and industrial applications.
Medical imaging is often perceived to designate the set of techniques that
noninvasively produce images of the internal aspect of the body. In this
restricted sense, medical imaging can be seen as the solution
of mathematical inverse problems. This means that cause (the properties of
living tissue) is inferred from effect (the observed signal). In the case of
ultrasonography the probe consists of ultrasonic pressure waves and echoes
inside the tissue show the internal structure. In the case of projection
radiography, the probe is X-ray radiation which is absorbed at different rates in
different tissue types such as bone, muscle and fat.
[edit]Imaging technology
[edit]Electron microscopy
Main article: Electron microscope
The electron microscope is a microscope that can magnify very small details
with high resolving power due to the use of electrons as the source of
illumination, magnifying at levels up to 2,000,000 times.
Electron microscopy is employed in anatomic pathology to identify organelles
within the cells. Its usefulness has been greatly reduced
byimmunhistochemistry but it is still irreplaceable for the diagnosis of kidney
disease, identification of immotile cilia syndrome and many other tasks
[edit]Radiographic
Main article: Medical radiography
Two forms of radiographic images are in use in medical imaging; projection
radiography and fluoroscopy, with latter useful for intraoperative and catheter
guidance. These 2D techniques are still in wide use despite the advance of 3D
tomography due to the low cost, high resolution, and depending on application,
lower radiation dosages. This imaging modality utilizes a wide beam of x
rays for image acquisition and is the first imaging technique available in modern
medicine.
 Fluoroscopy produces real-time images of internal structures of the body in a
similar fashion to radiography, but employs a constant input of x-rays, at a
lower dose rate. Contrast media, such as barium, iodine, and air are used to
visualize internal organs as they work. Fluoroscopy is also used in image-
guided procedures when constant feedback during a procedure is required.
An image receptor is required to convert the radiation into an image after it
has passed through the area of interest. Early on this was a fluorescing
screen, which gave way to an Image Amplifier (IA) which was a large
vacuum tube that had the receiving end coated with cesium iodide, and a
mirror at the opposite end. Eventually the mirror was replaced with a TV
camera.
 Projectional radiographs, more commonly known as x-rays, are often used
to determine the type and extent of a fracture as well as for detecting
pathological changes in the lungs. With the use of radio-opaque contrast
media, such as barium, they can also be used to visualize the structure of the
stomach and intestines - this can help diagnose ulcers or certain types
of colon cancer.
[edit]Magnetic resonance imaging (MRI)
Main article: Magnetic resonance imaging

A brain MRI representation

A magnetic resonance imaging instrument (MRI scanner), or "nuclear magnetic
resonance (NMR) imaging" scanner as it was originally known, uses powerful
magnets to polarise and excite hydrogen nuclei (singleproton) in water
molecules in human tissue, producing a detectable signal which is spatially
encoded, resulting in images of the body. MRI uses three electromagnetic
fields: a very strong (on the order of units ofteslas) static magnetic field to
polarize the hydrogen nuclei, called the static field; a weaker time-varying (on
the order of 1 kHz) field(s) for spatial encoding, called the gradient field(s); and
a weak radio-frequency (RF) field for manipulation of the hydrogen nuclei to
produce measurable signals, collected through an RF antenna.
Like CT, MRI traditionally creates a two dimensional image of a thin "slice" of
the body and is therefore considered a tomographic imaging technique. Modern
MRI instruments are capable of producing images in the form of 3D blocks,
which may be considered a generalisation of the single-slice, tomographic,
concept. Unlike CT, MRI does not involve the use of ionizing radiation and is
therefore not associated with the same health hazards. For example, because
MRI has only been in use since the early 1980s, there are no known long-term
effects of exposure to strong static fields (this is the subject of some debate; see
'Safety' in MRI) and therefore there is no limit to the number of scans to which
an individual can be subjected, in contrast with X-ray and CT. However, there
are well-identified health risks associated with tissue heating from exposure to
the RF field and the presence of implanted devices in the body, such as pace
makers. These risks are strictly controlled as part of the design of the instrument
and the scanning protocols used.
Because CT and MRI are sensitive to different tissue properties, the appearance
of the images obtained with the two techniques differ markedly. In CT, X-rays
must be blocked by some form of dense tissue to create an image, so the image
quality when looking at soft tissues will be poor. In MRI, while any nucleus
with a net nuclear spin can be used, the proton of the hydrogen atom remains
the most widely used, especially in the clinical setting, because it is so
ubiquitous and returns a large signal. This nucleus, present in water molecules,
allows the excellent soft-tissue contrast achievable with MRI.
[edit]Nuclear medicine
Main article: Nuclear medicine
Nuclear medicine encompasses both diagnostic imaging and treatment of
disease, and may also be referred to as molecular medicine or molecular
imaging & therapeutics [1]. Nuclear medicine uses certain properties of isotopes
and the energetic particles emitted from radioactive material to diagnose or treat
various pathology. Different from the typical concept of anatomic radiology,
nuclear medicine enables assessment of physiology. This function-based
approach to medical evaluation has useful applications in most subspecialties,
notably oncology, neurology, and cardiology.
 Gamma cameras are used in nuclear medicine to detect regions of biologic
activity that may be associated with disease. Relatively short livedisotope,
such as 123I is administered to the patient. Isotopes are often preferentially
absorbed by biologically active tissue in the body, and can be used to
identify tumors or fracture points in bone. Images are acquired after
collimated photons are detected by a crystal that gives off a light signal,
which is in turn amplified and converted into count data. Gamma cameras
can have a variable number of detector heads with two being the most
common configuration. 2D planar images can be acquired of the body or
multiple time-capture images can be combined into a dynamic sequence cine
of a physiologic process over time. A 3D tomographic technique known
 as SPECT uses gamma camera data from many projections and can be
reconstructed in different planes. A dual detector head gamma camera
combined with a CT scanner, which provides localization of functional
SPECT data, is termed a SPECT/CT camera, and has shown utility in
advancing the field of molecular imaging.
 Positron emission tomography (PET) uses coincidence detection to image
functional processes. Short-lived positron emitting isotope, such as18F, is
incorporated with an organic substance such as glucose, creating F18-
fluorodeoxyglucose, which can be used as a marker of metabolic utilization.
Images of activity distribution throughout the body can show rapidly
growing tissue, like tumor, metastasis, or infection. PET images can be
viewed in comparison to computed tomography scans to determine an
anatomic correlate. Modern scanners combine PET with a CT, or even MRI,
to optimize the image reconstruction involved with positron imaging. This is
performed on the same equipment without physically moving the patient off
of the gantry. The resultant hybrid of functional and anatomic imaging
information is a useful tool in non-invasive diagnosis and patient
management.
 Nuclear medicine therapy includes treatment with unsealed radioactive
material in various forms, including free beta radiation emitting isotope,
bound to antibody (radioimmunotherapy), and directly administered, as in
resin microsphere therapy. Imaging aspects to many of these therapeutic
procedures can add to the evaluation of efficacy.
[edit]Photoacoustic imaging
Main article: Photoacoustic imaging in biomedicine
Photoacoustic imaging is a recently developed hybrid biomedical imaging
modality based on the photoacoustic effect. It combines the advantages of
optical absorption contrast with ultrasonic spatial resolution for deep imaging in
(optical) diffusive or quasi-diffusive regime. Recent studies have shown that
photoacoustic imaging can be used in vivo for tumor angiogenesis monitoring,
blood oxygenation mapping, functional brain imaging, and skin melanoma
detection, etc.
[edit]Breast Thermography
Needs main article Digital Infrared Imaging Thermography is based on the
principle that metabolic activity and vascular circulation in both pre-cancerous
tissue and the area surrounding a developing breast cancer is almost always
higher than in normal breast tissue. Cancerous tumors require an ever-
increasing supply of nutrients and therefore increase circulation to their cells by
holding open existing blood vessels, opening dormant vessels, and creating new
ones (neoangiogenesis). This process frequently results in an increase in
regional surface temperatures of the breast. Digital Infrared Imaging uses
extremely sensitive medical infrared cameras and sophisticated computers to
detect, analyze, and produce high-resolution diagnostic images of these
temperature variations. Because of DII’s sensitivity, these temperature
variations may be among the earliest signs of breast cancer and/or a pre-
cancerous state of the breast[2].
[edit]Tomography
Main article: Computed tomography
Tomography is the method of imaging a single plane, or slice, of an object
resulting in a tomogram. There are several forms of tomography:
 Linear tomography: This is the most basic form of tomography. The X-ray
tube moved from point "A" to point "B" above the patient, while the cassette
holder (or "bucky") moves simultaneously under the patient from point "B"
to point "A." The fulcrum, or pivot point, is set to the area of interest. In this
manner, the points above and below the focal plane are blurred out, just as
the background is blurred when panning a camera during exposure. No
longer carried out and replaced by computed tomography.
 Poly tomography: This was a complex form of tomography. With this
technique, a number of geometrical movements were programmed, such as
hypocycloidic, circular, figure 8, and elliptical. Philips Medical
Systems [1] produced one such device called the 'Polytome.' This unit was
still in use into the 1990s, as its resulting images for small or difficult
physiology, such as the inner ear, was still difficult to image with CTs at that
time. As the resolution of CTs got better, this procedure was taken over by
the CT.
 Zonography: This is a variant of linear tomography, where a limited arc of
movement is used. It is still used in some centres for visualising the kidney
during an intravenous urogram (IVU).
 Orthopantomography (OPT or OPG): The only common tomographic
examination in use. This makes use of a complex movement to allow the
radiographic examination of the mandible, as if it were a flat bone. It is often
referred to as a "Panorex", but this is incorrect, as it is a trademark of a
specific company's equipment
 Computed Tomography (CT), or Computed Axial Tomography (CAT): A
CT scan, also known as a CAT scan, is a helical tomography (latest
generation), which traditionally produces a 2D image of the structures in a
thin section of the body. It uses X-rays. It has a greater ionizing
radiation dose burden than projection radiography; repeated scans must be
limited to avoid health effects.
[edit]Ultrasound
Main article: Medical ultrasonography
Medical ultrasonography uses high frequency broadband sound waves in
the megahertz range that are reflected by tissue to varying degrees to produce
(up to 3D) images. This is commonly associated with imaging the fetus in
pregnant women. Uses of ultrasound are much broader, however. Other
important uses include imaging the abdominal organs, heart, breast, muscles,
tendons, arteries and veins. While it may provide less anatomical detail than
techniques such as CT or MRI, it has several advantages which make it ideal in
numerous situations, in particular that it studies the function of moving
structures in real-time, emits no ionizing radiation, and contains speckle that can
be used in elastography. It is very safe to use and does not appear to cause any
adverse effects, although information on this is not well documented. It is also
relatively inexpensive and quick to perform. Ultrasound scanners can be taken
to critically ill patients in intensive care units, avoiding the danger caused while
moving the patient to the radiology department. The real time moving image
obtained can be used to guide drainage and biopsy procedures. Doppler
capabilities on modern scanners allow the blood flow in arteries and veins to be
assessed.
[edit]Medical imaging topics
[edit]Creation of three-dimensional images
Recently, techniques have been developed to enable CT, MRI and ultrasound
scanning software to produce 3D images for the physician. Traditionally CT and
MRI scans produced 2D static output on film. To produce 3D images, many
scans are made, then combined by computers to produce a 3D model, which can
then be manipulated by the physician. 3D ultrasounds are produced using a
somewhat similar technique.
With the ability to visualize important structures in great detail, 3D visualization
methods are a valuable resource for the diagnosis and surgical treatment of
many pathologies. It was a key resource for the famous, but ultimately
unsuccessful attempt by Singaporean surgeons to separate Iranian twins Ladan
and Laleh Bijani in 2003. The 3D equipment was used previously for similar
operations with great success.
Other proposed or developed techniques include:
 Diffuse optical tomography
 Elastography
 Electrical impedance tomography
 Optoacoustic imaging
 Ophthalmology
 A-scan
 B-scan
 Corneal topography
 Optical coherence tomography
 Scanning laser ophthalmoscopy
Some of these techniques are still at a research stage and not yet used in clinical
routines.
[edit]Non-diagnostic imaging
Neuroimaging has also been used in experimental circumstances to allow
people (especially disabled persons) to control outside devices, acting as a brain
computer interface.
[edit]Open source software
Several open source software packages are available for performing analysis of
medical images:
 ImageJ
 ITK
 DICOMWORKS
 GemIdent
[edit]Proprietary software
 Analyze
 MIMViewer
 SureVistaVision
 Universal PACS
 Simpleware ScanIP
[edit]Use in Pharmaceutical Clinical Trials
Medical imaging has become a major tool in clinical trials since it enables rapid
diagnosis with visualization and quantitative assessment.
A typical clinical trial goes through multiple phases and can take up to eight
years. Clinical endpoints or outcomes are used to determine whether the therapy
is safe and effective. Once a patient reaches the endpoint, he/she is generally
excluded from further experimental interaction. Trials that rely solely
on clinical endpoints are very costly as they have long durations and tend to
need large number of patients.
In contrast to clinical endpoints, surrogate endpoints have been shown to cut
down the time required to confirm whether a drug has clinical benefits.
Imaging biomarkers (a characteristic that is objectively measured by an imaging
technique, which is used as an indicator of pharmacological response to a
therapy) and surrogate endpoints have shown to facilitate the use of small group
sizes, obtaining quick results with good statistical power.[3]
Imaging is able to reveal subtle change that is indicative of the progression of
therapy that may be missed out by more subjective, traditional approaches.
Statistical bias is reduced as the findings are evaluated without any direct
patient contact.
For example, measurement of tumour shrinkage is a commonly used surrogate
endpoint in solid tumour response evaluation. This allows for faster and more
objective assessment of the effects of anticancer drugs. In evaluating the extent
of Alzheimer’s disease, it is still prevalent to use behavioural and cognitive
tests. MRI scans on the entire brain can accurately pinpoint hippocampal
atrophy rate while PET scans is able to measure the brain’s metabolic activity
by measuring regional glucose metabolism. [4]
An imaging-based trial will usually be made up of three components:
1. A realistic imaging protocol. The protocol is an outline that standardizes (as
far as practically possible) the way in which the images are acquired using the
various modalities (PET, SPECT, CT, MRI). It covers the specifics in which
images are to be stored, processes and evaluated.
2. An imaging centre that is responsible for collecting the images, perform
quality control and provide tools for data storage, distribution and analysis. It is
important for images acquired at different time points are displayed in a
standardised format to maintain the reliability of the evaluation. Certain
specialised imaging contract research organizations provide to end medical
imaging services, from protocol design and site management through to data
quality assurance and image analysis.
3. Clinical sites that recruit patients to generate the images to send back to the
imaging centre.