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Medical Imaging Louis Kreel Postgrad Med J: first published as 10.1136/pgmj.67.786.334 on 1 April 1991. Downloaded from Postgrad Med J (1991) 67, 334 - 346 i) The Fellowship of Postgraduate Medicine, 1991 Reviews in Medicine Medical imaging Louis Kreel Department ofDiagnostic Radiology, Prince of Wales Hospital, Shatin, N. T., Hong Kong Introduction Physicists have tapped the electromagnetic spec- latitude with lower radiation and minimal repeat trum to great effect. Each energy wave-form that examinations. Dark rooms for film processing will penetrates tissues has a corresponding imaging disappear. Fluoroscopy too will be fully automated system, starting with Roentgen's radiograph of his and digitized, and all radiographs will show the full wife's hand in 1895. Since then gamma rays, range of radiodensities from lung, through soft X-rays, protons, ultrasound and radiofrequency tissues to bone with one exposure. This will entail coupled to a magnetic field have been grafted onto new equipment, film, cassettes and imaging systems computers to produce anatomical images varying at considerable expense. in type and detail. More recently these modalities Furthermore, each passing year sees the intro- have produced sophisticated physiological data of duction of new scanners with shorter scanning considerable interest. times and higher spatial resolution, producing Thus the words 'digital' and greater detail and 'computer' have more information. Millisecond copyright. invaded radiology departments, not only with computed tomography (CT), cardiac cine, scanners, of which they are integral components, magnetic resonance imaging (MRI) down to but also in conventional fluoroscopy and radio- breath-holding time, and the technology of CT graphy. The change is as revolutionary as that of applied to nuclear medicine (NM), yielding single steam engine to internal combustion engine or photon emission CT and proton emission tomog- automobile to aeroplane. The costs too are com- raphy, are now available. parable for the equipment, although in the long run With this equipment and the development ofnew the cost ofpatient care will remain unchanged or be radionuclides as well as MRI spectroscopy, which http://pmj.bmj.com/ even less ifthe rapidity and accuracy ofdiagnosis is is at present being evaluated in clinical practice, taken into consideration. windows to cerebral activity in health and disease So much for analogies. What, then, in broad have been opened. The research emphasis in imag- outline is new? PACS, the picture archiving and ing is thus changing from morphology to function, communications systems, if fully operational, will particularly in the heart and brain. create hospitals without radiographic film. Images However, the great and elusive goal of tissue will be transmitted instantaneously within hos- characterization has not been fulfilled with either pitals, between hospitals, across the country and CT or MRI. The search continues with magnetic on September 28, 2021 by guest. Protected between continents, with greater contrast and resonance spectroscopy (MRS) in the hope of resolution by tele-video communication. Archiving distinguishing granulomas and tumours, benign and recall will also be nearly instantaneous. In from malignant, or even to go further by assessing addition, the clinical details, biochemistry and the degree of malignancy. The ultimate aim of available pathology will appear on the screen. diagnostic imaging then is to produce complete Radiology departments will become diagnostic morphological and functional information, departments of medical imaging. thereby equalling the achievements of histology. In the interim, conventional radiography is being MRS and NM individually or in combination are automated, with radiographers concentrating on also being applied to metabolic diseases. the patient's well-being, on reassuring the patient The magic and art of imaging resides with and on careful positioning. The radiographs will be sonography, where the hand-held probe sees processed in daylight, having greater definition and directly into the body, now extending its scope even further with colour Doppler, endoscopic sono- graphy and peroperative applications. As the centenary of Roentgen's discovery Correspondence: L. Kreel, M.D., F.R.C.P., F.R.C.R. approaches we can perceive how X-rays are slowly Postgrad Med J: first published as 10.1136/pgmj.67.786.334 on 1 April 1991. Downloaded from MEDICAL IMAGING 335 but surely being ousted from their pre-eminent Video consoles are an essential component ofall position in medical imaging, giving way to non- scanners. The images are seen in real time during ionizing electromagnetic energies. In fact it is sonography, almost in real time with the newest CT extremely doubtful if a modern ethical committee and MRI equipment, then shown as static images would allow the use ofX-rays in clinical practice if for interrogation or as a dynamic cine loop study. presented as a new discovery. On the basis of Nuclear medicine and Doppler sonography are animal experiments the effects of X-rays would often shown in colour. Yet very few departments probably be considered unacceptable. In the his- have a central viewing area where the various tory of medical imaging the 20th century may well images can be integrated. be designated as the century of iatrogenic radia- At present, then, these video consoles are part of tion, medical imaging having replaced radiology. the equipment used during the examination or only within the confines of the particular diagnostic suite and are not available for interdisciplinary The radiology department consultations when the information from 2 or more examinations needs to be correlated, especially The production, filing and delivery of radiographs angiography and CT or the various sequences of to the wards, out-patient department and theatre MRI. The correlation of sonograms with other are tedious and labour-intensive tasks. Subse- scanning procedures and isotope scans with plain quently their retrieval for re-filing is often difficult films are other examples. The advantages for and fraught with recriminations: the vital and consultations and teaching are self evident. interesting film is always the one that is missing or A system that will permit the simultaneous lost. Storage of film requires a large space, partic- viewing and integration of the various images ularly as radiographs must be kept for at least 7 necessitates their on-line transmission to a central years. Many departments and hospitals would like archive whence they can be viewed at one or more to have follow-up studies for even longer periods, areas such as a consultation studio or the surgical especially orthopaedic surgeons and chest operating suite. In the first instance the images physicians. Frequently operations and consulta- must be available to radiologists for their immed- copyright. tions cannot proceed without the relevant films. iate assessment to conclude the examination and This holds true also for interdisciplinary case for reporting. Simultaneously the images are stored presentations, particularly for tertiary referrals, in the central archive where the various modalities Furthermore, transmitting radiographic inform- are integrated for future display. ation verbally or in writing is often ambiguous. To be effective the archive must be able to hold Picture archiving and retrieval systems (PACS)' the vast amount ofinformation and to reformat the can eliminate these difficulties, but require the data image. Either more powerful computers are needed in digital form. or there must be compression of the images but http://pmj.bmj.com/ Most medical images are or can be digitized, with no loss of detail. Such compression systems including not only NM, CT, MRI and obviously have now been produced with ratios of 5-10:1. digital subtraction angiography (DSA) but also, in The transmission of medical images from one the not too distant future, plain film radiography. location to another is called teleradiology' and Digital images have many advantages for viewing, wide area networks are already in existence. A laser storage, retrieval and transmission. film digitizer with an optical disc and a laser printer The image on a video monitor can be modified in are essential for high-quality images. A variety of a number of different ways and interrogated. Part technologies are used for the communication net- on September 28, 2021 by guest. Protected or all of the image can be enlarged or diminished, work, including co-axial cables, fibre-optic links, measured, annotated, reversed, and windowed to switched circuits and satellite transmission pro- show the different tissue densities of bone, soft viding immediate images to the accident and tissue or lung, and these densities can be measured. emergency department and intensive care unit. Sectional images can be reconstructed into other Outlying hospitals or clinics can communicate with planes or into D-3 and optimized for spatial and their large central counterparts or academic insti- contrast resolution. Hard copy of these images is tution before admission is arranged. frequently a poor substitute for viewing the images In the United Kingdom and many other coun- on a monitor, resulting in a loss of important tries these major developments will concern only a information. The small subdural haematoma is an small number of institutions. Many more will be example. Unless the CT sections are shown at a affected by the prospect ofthe greater resolution to wide window, it will be
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