Sudan University of Science & Technology

College of Medical Radiological Science

Department of Radiological Technology

SD0000012

IMAGING ARTIFACTS
Comparative Sludy in
X- Ray Ct & Medical Ultrasound

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MayVAohamed W\edan\
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Supervised by.
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July 1998-Khartoum
I
2. CONTENTS.

1.1 RESEARCH PROPOSAL.

1.2 INTRODUCTION.
 Contents

Part one (1)

Section one [1]
1. Acknowledgement.
2. Contents.
1.1 Research Proposal.
1.2Introduction.
Part two (2)
2.1 Artifacts in X-RayCT.
2.1.1 Equipment
2.1.2 .Technique
2.1.3 Patient
2.2 Reducing of Artifacts inCT.
2.2.1 Equipment
2.2.2 Technique
2.2.3 Patient
Part three (3)
3.1 Artifact in Medical Ultrasound.
3.1.1 Equipment
3.1.2 Technique
3.1.3 Patient
3.2 Reduction of Artifacts in Ultrasound
3.2.1 Equipment
3.2.2 Technique
3.2.3 Patient
Part Four (4)
4.1 Comparative Studies Tables.
4.2 Data Collection.
4.3 Discussion of Results.
Part Five (5)
5.1 Q.C
5.2 Conclusion & Recommendation
Reference
Appendix
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 Chapter One
Research Proposal:
Imaging Artifacts: A Comparative Study
In X-Ray CT & Medical Ultrasound
Introduction:
This study draws attention forwards the quality of imaging process.
Concerning the factors that may observe the diagnosis out come which
represents the aim of the whole process of imaging technology. Imaging
artifacts is one of the major limitation factor that after and decrease the
value of diagnosis and out come in conventional radiography we can
estimate the factors that cause artifacts which could be easily evaluated
because most of the parameters in imaging process are fixed to some
extend and the accessing of the imaging approximately in direct mode.
But the errors which leads to artifacts skill arise in digital imaging
"Concerning CTV U/S", the accessing process taken over several steps
involve conversion from analogue format to digital and vice versa; and
application of computer technology program needs careful awareness.
Tiny errors many arise artifact, issue, errors leads to artifact, on digital
imaging can't predicted unless listed and discussed on a cord of practices
according to the operational protocol.
Statement of problem:
The digital imaging nowadays cover most of investigations done in
radiography department ever the conventional process started earlier and
cover along of time and the technologist gain experience skill errors lead
to artifacts seem to be more while digital imaging replace the conventional
imaging in a fast steps it carry also the same errors with the new errors,
that may warser the new practice as a whole.
 Reasons for Choice This Project:
There were a lot of errors in different department that deals with
digital imaging can be observed by any general observer this issue
reflected on the fetal report at the level of diagnosis and this will affect the
quality of patient cane and may be the morbidity rate as well as mortality
rate.
Objectives of the Project:
The main objective of this study is to high light the artifacts and the
source of errors that lead to artifact formation and we can summarize the
main objectives on the following points:
(1) Consider and identify the artifacts on each modality.
(2) Show the cause of artifact.
(3) Resolve and eliminate the reasons that lead to artifacts
formation in imaging.
(4) Establish proper quality control techniques issue set tha base
line limits of artifact causation.
Hypothesis:
1- The presence of artifact creates problems in diagnosis.
2-The cause errors leading to imaging artifact that affect the
diagnosis more in digital U/S than CT.
3- Lack of quality assurance programs maximizes the presence of
faults leading to imaging artifact.
4- Imaging artifacts affects the quality of patient care and delay
medical diagnosis and treatment, and hence increase patient
waiting time.
 Previous Studies:
From what we read in the previous research studies (1,2,3) we did
notice that there was just listing of faults without indicating any reason (s)
or causes except in medical ultrasound. However, we planned to research
it from our locate experts in CT and medical ultrasound in the teaching
hospitals and medical centres according to the values of the code of
practice.
Research Methodology:
In this study of have taken the scientific method in the field of X-ray
CT and medical ultrasound imaging.
Data Collection:
1-Questionnaire.
2- Interviews.
Using both in the following variable:
a. Equipment factors.
b. Patient factors.
c. Technique.
Place & Period of Study:
Sudan- Khartoum March/July 1998 (Teaching Hospitals and Medical
Imaging Centers).
 Introduction
Diagnostic imaging is an important element in the practice of the
modern medicine without it medical treatment would have been
impossible. Radiation medicine had seen many changes since 1895, where
only early tuals. A radiation therapy and radoidiagnosis. Today imaging
has many source of electromagnetic radiation "EMRs" and each source
has its advantages over the other. However, medical radiation education
had also seen more advances in the medical sciences and medical
education, which lead to the discoveries of new methods, and techniques
in these fields.
There were also new approaches to refine and perfect the practice of
radiologic techniques and to reduce radiation exposure, patient waiting
time and cost. We have seen lots of new imaging modalities, quality
assurance and quantity control procedures in all modalities to produce
images of high quality and more diagnostic information.
Here, we have taken the lead to research and study carefully how we
could participate in the area of reducing image retakes and study the
reasons of image artifacts in diagnostic imaging.
In this regaid we are researching on artifacts in X-ray computed
tomography and medical ultrasound and considering how these artifacts
may be eliminated.
 PART 10W

ARTIFACTS IN X-RAY CT.

2.1.1 TECHNIQUE
2.1.2 EQUIPMENT
2.1.3 PATIENT
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8
 Artifacts
This section deals with experience gained with the original model

EMI 160 xl60 matrix scanner. Modification, because of the experience

with EMI CT 1010 scanner and other scanning systems, is expected. This
section should be of considerable value in the understanding of the basic
causes of artifact production and sources of error despite such
modifications.

Artifacts:
Motion and high-differential attenuation value of adjacent tissues are
principal cause of artifacts. Technical errors are also responsible.

Motion Artifacts:
Motion of a point places that point different computed positions
during the scanning cycle. This false representation usually produces a
linear artifact called a "streak". Point A scanned at 0 degree is again
scanned at 180 degrees with an interval time delay. A change in point A
position will produce computer error in the form of a streak. Computer
error due to movement will, therefore, be more marked along the vertical
(Odegree/180degrees) line, because of motion during the time that elapses
between the two readings. The head can rotate in all directions, producing
a variety of streaking outside or inside the skull vault. Assuming that the
scanning time is constant, head support, patient cooperation and sedation
are factors to consider in order to diminish motion artifact. The faster
scanning cycle of the newer CT systems reduces the degree of motion
artifact. The EMI CT 1010 scanner has a 240-degree scanning angle
option designed to decrease streaking that result from patient motion.

High-Attenuation Differential Artifacts:

Streaking also occurs at interfaces of high-attenuation differentials,
such as air-bone, air-brain, bone-brain and metal-brain. The computer
"overloads" due the high differential values and produces the streak.

The high-Vat dense petrous pyramids possibly combined with air in

the ears may cause transpontine streaking that obscures the
cerebellopotine angle. Surgical clips, metallic plates, Holder valves and
shunt reservoirs produce streaking. Using a scanning angle of 240 degree
or starting the scanning cycle at 90 degree can be helpful in decreasing
artifacts due to metal or other high-differential attenuation situation.

Postpneumeoncephalography air can produce streaking or simply

"overshoot" at the air-fluid level. Overshoot appears as thin band of
contrasting Vat adjacent to the zone of the high-differential values.
Nevertheless, CT scanning in the presence of air or other contrast in the
subarachnoid space can be diagnostically useful. Overshoot also produces
a thin band of low Vat subjacent to the skull (the false subarachnoid
space). A zone of artifactiually increased Vat simulates "gray matter" on
the original EMI scanner. This overshoot phenomenon is seen subjacent to
the false subarachnoid space. Other mechanisms than overshoot may also
be responsible for the false gray matter. More modern machines are
apparently able to demonstrate true gray matter. Elimination of metal from
shunt mechanisms eliminates metallic-streak artifacts.

10
Source of Error:
Technical source of error includes improper selection of window
level and window width, improper Polaroid printing and improper patient
positioning. Several other situation are also potential sources of error,
including "partial-volume" phenomenon and incorrect measurement of
surface area. The partial volume phenomenon is the effect of matrix
averaging of heterogeneous tissues. Partial volume phenomenon leads to
misinterpretation, such as spurious "hydrocephalus" Postpneumeonce-
phalography. It also leads to Vat and volumetric measurement error,
particularly of small highly contrasting regions. Use of the higher detail
matrix systems, combined with thin-section technique, diminishes this
averaging problem. Magnification factors for measurement must be
accurately calculated in order to avoid misrepresentation of size. This
calculation should based on data obtained by scanning a phantom of
known dimension, or by measurement of structure of known size that
appears on the CT scan.

The level of section may also be misinterpreted. Systems to locate

accurately the plane of section have been developed. Sagittal CT
sectioning devices are still in the experimental stage. Coronal section
technique is discussed in chapter 13.

Human sources of error in interpretation also occur. The jugular

tubercle may be prominent and is found at high level in basilar
invagination. In such cases, the jugular tubercle may mimic a high-Vat
lesion such as a meningioma or acoustic neurinoma.
 PART TOW

2.12

ARTIFACTS IN X-RAY CT.

TECHNIQUE
Technical Artifacts:

Indexing inaccuracies produce a characteristic linear artifact called

"herringbone" artifact. High signal/noise ratio is necessary for a high-
quality scan. As the signal/noise ratio diminishes, a mottled compromised
image results as with improper tubecrystal alignment or inherent fault in
tube or crystal. Technical error can also produce artifacts. Changing
crystal photomultiplier technique during the scanning cycle will produce a
characteristic linear artifact.
Figure (I)

Technical Error Artifact Troticollosed

Patient, Pantopaque Droplets

Section IB (conventional scan). The higher

right petrous pyramids (PP) and orbital rooF
(OR) appears in this plane of section due to
patient troticollis. Pantopaque droplets
(arrows) surround brain stem. Displacement of
the fourth ventricle (4) toward the right side is
suspected, but difficult to confirm

Figure (2)
llasilnr Impression, Prominent Dens, and
Jugular Tubercles

Section IA (conventional scan). Prominent

jugular tubercles (JT) posterior to petrous
pyramids (PP). Dens behind lower aspect of
clivus(CL) Globe (G).

Figure(3)

Technical Error Artifact

Characteristic linear artifact caused by

changing crystal photomultipiier technique
during the scanning cycle

IP-
 PART TOW

1.2

ARTIFACTS IN X-RAY CT.

EQUIPMENT

is
 Figure (1!)

Indexing Error Artifact

Herringbone pattern caused by indexing error

Figure ( 1 2 )

X-ray Tube - Crystal Alignment Artifact

Molt led artifact produced by improper tube-

crystal alignment

Figure ( 1 3 )

High-Differential Metal-Brain Artifact-

Streak

Surgical metallic clips causing computer

overload with resultant streaking.

16
Figure (14)

High-Differentia! Hone-Brain Vat Artifact-

Overshoot

Section 2A (conventional scan). Thin black

band of false subarachniod space (!) Thicker
band of false gray matter (2)

Figure (15) a and b

Artifacts

In order to eliminate metal-bone and metal-

brain artifact due to ventricular shunting,
reservoirs and valves made of plastic can be
used

(a) Section 2B (conventional scan)

(b) Section 3A (conventional scan)

Fimbriated tip of high-Vat shunts (arrow) in

right frontal horn Left frontal horn (FH)
Choroid plexus (CP). Subdural hematoma
(arrowheads) No streaking from base of shunt
tube (SH) due to lack of metal Left ventricle
(I.V).
Figure (16) n and b

Overshoot Artifact anil Partial Volume

Phenomenon Computer Tomographic
Pneunwencephahgram

Brovv-up (a) and brow-down (b) scans at

frontal horn level. Brow-down (b) section
closer to infraorbitomeatal plane than brovv-up
(a) High-and low-Vat streaks at air margins,
particularly in the vertical direction, are noted.
Atrium (AT), third ventricle (3),
interhemispheric (IMF) and Sylvian fissures
(SF). quadrigeminal plate (QPC) and superior
cerebella cisterns (SCC), frontal horn (FH).

The seemingly larger frontal horns brow-up is

mostly an illusion due to averaging of air and
brain tissue at the ventricular margin. This
average is therefore heavily weighted toward
the appearance of larger frontal horn on the
Polaroid print. Careful examination of the
brow-down section reveals almost the same
size frontal horn There probably is a degree of
ventricular expansion with air filling, however,
Figure (18)

High-Differential Metal-lirain Artifact-

Streak

Severe streaking caused by frontal bone

metallic

Figure ( 1 9 )

High-Differential Air-Brain Artifact-

Overshoot

Section 2B (postventriculogram). Air also

present in subarachnoid space. Frontal horn air
(FH A) Overshoot horizontal interface
(arrows) between air and CSF (AVat= 1000) of
frontal horns Subarachnoid air outlines
subarachnoid cyst (CY) anderiorly
(arrowheads). Lateral ventricle atrium (AT)

i9
 PART TOW

2.1.3

ARTIFACTS IN X-RAY CT.

PATIENT
Figure(4)

High-Differential Bone-Brain Artifact-Streak

Multiple spurious high-Vat zones (arrows)

subjacent to bone obscuring posterior fossa
anatomy. Motion contributes to streaking in
this case Combined causes of artifacts are very
common

Figure(5)

High-differential Bone-Brain Artifact-Streak

A transpontine low-Vat streak (arrow) is often

produced in association with dense petrous
pyramids Inion bone-brain streak (crossed
arrow)

Figure(6)

Motion Artifact-streak

Multiple vertical streaks (white lines) at scan

periphery caused by patient motion
Figure (7)

Motion Artifact-streak

Multiple streaks inside and outside of brain

image produced by patient motion.

Figure(8)

High-Differential Air-Skull Artifact-streak

The large quantity of air surrounding the small

head results in "lighten image-like" streaking.
Replacement ofthe water bag and adjusting the
photomultiplier technique in the EMI CT 1010 VVx
scanner alleviates this type of difficulty.

Figure(9)

High-Differential Air-Drain Artifact-Streak,

Partial Volume Phenomenon

Reciprocal high- and low-Vat artifactual zones

(arrows) surrounding air-filled frontal horns.
These streaks are the result of computer
overload The impression of frontal horn
dilation is largely due to computer averaging
(partial volume phenomenon). Normal-sized
third ventricle (3), atria (AT), and left occipital
horn (Oil)
 PART THREE

3.1

ARTIFACTS IN MEDIGAL ULTRA SOUND

3.1.1
EQUIPMENT
Sonogram Abbreviations:
BI: Bladder

D: Diaphragm

E: Echoes

GBI: Gallbladder

K: Kidney

L: Liver

P: Pleural effusion

RK: Right Kidney

T: Tornado effect

Ut: Uterus

Artifacts in ultrasonic images can be classified into three categories:

1. Artifacts related to instrument problems, which occur when the

equipment is not functioning satisfactory.
2. Technique-dependent artifacts, in which the appearance is
produced by unsatisfactory operator technique.

3. Artifacts due to the way tissues affect sound. These artifacts

cannot be avoided.
Each of these spurious sonographic appearances must be recognized
so that the deceptive finding can be disregarded, eliminated, or used as a
diagnostic aid.

This chapter will initially cover artifacts relating to real-time and

static scanning, and then artifacts seen with static scanning only.
Artifactiual Noise:
Artifactual noise is caused by electrical interference from nearby
equipment e.g. in an intensive care unit; Figure (20).

RECOGNITION Such noise has a repetitive pattern unlike the overall

increase in echogenicity seen with too much gain. This type of noise
produces a "pattern" over the normal ultrasound image.

FIGURE X ° Interference from nearby equipment causes artifacts on the CRT (arrow).

Figure (20): Interference from nearby equipment causes artifacts on the CRT
(arrow).

Calibration Problems-Incorrect
Distance Markers

Calibration problems may not be apparent on the image, but

subsequent measurements using another ultrasonic system or phantom
may show erroneous caliper measurements.

DIAGNOSTIC CONFUSION Measurements such as the biparietal

diameter may be wrong with tragic clinical consequences.

RECOGNITION Only by comparison with other systems or by

calibratior] check can such subtle measurement changes be detected.
Main Bang Artifact:

There can be many echoes from the skin-transducer interface in the

immediate subcutaneous tissues. There is such a strong interface between
the skin and the transducer that it is almost impossible to avoid the main
bang artifact completely with older transducers. Witli new technology, this
artifact is seldom seen because of electronic focusing. Poor technique,
however, can still create this artifact (Figure 22).

DIAGNOSTIC CONFUSION: Subuctaneous and skin lesions will be

hidden within the main bang artifact.

riOUBE 400 Main bang artifact With older units this is caused by a strong interface between
skin and the transducer. Too much near gain (arrow) can also be a reason

Figure (22): Main bang artifact. With older units this is caused by a strong interface
between the skin and the transducer. Too much near gain (arrow) can also be a reason
Veiling:
Bands of increased echogenicity can be seen at certain depth if all
focal zones are used simultaneously, producing the veiling artifact (figure
23).
DIAGNOSTIC CONFUSION The impression of a mass may be created
within the area of veiling. Masses may be overlooked at the interface of
the different focal zones.

RECOGNITION A band of increased echoes unrelated to the strong

interfaces within the images is seen at a certain depth.

FIGURE J^TVeiling. Focusing zones are well delineated transverse echo areas (arrows). Utilize
only the focusing zone in the area of interest to eliminate the focal banding.

Figure (23): Veiling Focusing zones are well-delineated trs isverse echo areas
(arrows) Utilize only the focusing zone in the area of interest to eliminate the focal
banding

J27
A bsence of Focusing:
Electronic focusing and the use of acoustic lenses have increased the
number of focal zones available with a single transducer and greatly
increased the resolution of the image. If the focal zone option is not used
with newer electronic systems much blurring of echo interfaces is seen
(Figure 24).

DIAGNOSTIC CONFUSION Discrete lines appear thick, and subtle

masses may be overlooked.

RECOGNITION. The echoes in the unfocused area are large. Echoes

normally seen as dots in the image are seen as a short line.

Figure (24): Absence focusing. There is blurring of the echoes when focusing is not
utilized (arrow)

28
Focusing and Persistence versus Festal Heart Motion:
"Focusing" and "persistence" improve the quality of the image at the
expense of frame rate; a wavy motion across the image is commonplace if
these controls are used.

DIAGNOSTIC CONFUSION Structures that move rapidly such as the

fetal heart may not be seen, and one can erroneously infer that a fetus is
dead.
RECOGNITION: A wavy image motion is visible when the image is
closely examined. Rapid motion of the transducer exaggerates this finding.
Grating lobes:

A grating lobe artifact is caused by the periodic spacing of the phased

array or, more commonly, linear array elements. Grating lobes travel at an
angle to the main beam, and depending on whether the lobe hits the object
before or after the main beam, a curvilinear echo may be seen either at a
shallower or deeper depth than the structure causing the artifact (figure 26)

DIAGNOSTIC CONFUSION An apparent septum may be present

within an amniotic sac or other cystic process.

RECOGNITION: The septum, which is slightly curved, is usually related

to a strong curvilinear interface in the mid-portion of the linear array field.

Figure (26): A grating artifact (arrow) may sometimes occur above or below a strong
linear interface ( e g the diaphragm) when using an array system, particularly a linear
array
Photographic Artifacts:

Photographic artifacts are a major problem. If the contrast is set

incorrectly, subtle metastatic lesions may be lost in the overall grayness of
the image. Undue brightness may also obscure subtle texttiral alterations.

Dust on the Camera:

If dust is allowed to settle onto a camera lens or cathode ray tube,
small echo-genic areas will be seen on the camera image. Similar artifacts
can occur with Polaroid images (figure 27).

DIAGNOSTIC CONFUSION If the echogenic mass lies within the liver,

confusion with a metastatic lesion may occur.

RECOGNITION: A similar echogenic area occurs in the same location on

every film.

Figure (27): A

31
 PART THREE

%Mm l a MM

ARTIFACTS CAUSED RY TECHNIQUE:

3-2
Noise:

Noise is created by excess gain (figure 28). Gain may be turned up to

a point where low-level echoes occur in unstructured fluid-filled areas
such as the bladder.

DAIGNOSTIC CONFUSION: Excess gain may give the impression that

the crystic lesion contains internal material or is solid.
Figure (28): Low-level echoes (noise) are seen in the fluid-filled bladder.

Side Lobes:

Side lobes are secondary echoes outside the main beam, that exist
with all transducers.

DIAGNOSTIC CONFUSION Noise is created within the image.

RECOGNITION: Recognition is difficult unless quality control tests are
performed.
Operator scanning speed:

If the sonographer scans rapidly, artifacts known as dropout lines are

created (figure 29). Most digital units receive information rapidly enough
to avoid this artifact. Some units appear to have gaps between the lines of
the image because they have not been "smoothed". Computer processing
can eliminate these little gaps between beam lines in cosmetic but
uninformative fashion (i.e. the gaps are filled in with false echoes).

Figure (29): Dropout lines (arrows) are created when the scanning speed is too rapid
Operator Pressure:
Applying too much or uneven pressure while scanning can distort the
image.

DIAGNOSTIC CONFUSION Scanning the fetal trunk using too much

pressure with a linear array may make it appear to have a flattened ovoid
shape rather than the preferred round shape (figure 30).

Figure (30): Pressure artifacts. A. Too much pressures over the fetal trunk produces a
flattened ovoid shape. B. A. Lighter scanning pressure creates a round mink and
correct measurement
 PART THREE

3.1.3

Artifacts Caused by Sound-tissue

Patient
Artifacts from Strongly Reflective Structures (Shadowing):
Gas, bone, and, to a much lesser extent, muscle do not conduct sound
well. When sound strikes a strong interface such as gas or bone, one of
two responses may be produced. Either there is no sound conduction
through the area (shadowing), or numerous secondary reverberations are
produced, causing a series of echogenic lines extending into the tissues
(ring down).

DIAGNOSTIC CONEUSION Large-shadowing artifacts may obscure a

deep pathologic process (e.g. nodes).

RECOGNITION. The reverberation pattern seen with bones is series of

alternating lines (figure 31 A), whereas that seen with gas is usually a
more diffuse, vaguely outlined pattern with considerable noise - the
"tornado" effect. A linear series of parallel bands may also be seen with
gas - the "ring down" effect (figure 31 B).

CORRECTION TECHNIQUE The sonographer should attempt to scan

around gas or bone, obtaining scans of the areas below these structures
from an oblique angle.

Figure (31): Reverberation artifacts. A. A longitudinal scan of the thing. Notice

the reverberations (alternating lines) extending below the bone interface
(arrows). B. Gas may cause the creation of a line of reverberation echoes
(arrow), the "ring down" effect, or a vague sonolucent area of acoustic
shadowing, the "tornado" effect.
Benefit: Shadowing occurs when the sound beam hits a highly reflective
surface such as gallstones, renal stoner, or surgical clips, allowing a
diagnosis of an acoustically dense structure. The shadowing can be made
more obvious by increasing the frequency of the transducer (figure 32).

Figure (32): Large acoustic interfaces due to gallstone are associated with shadowing
(arrow). Shadowing is accentuated with higher frequency.
Reverberation Artifacts:
Whenever sound passes out of a structure with an acoustic impedance
that is markedly different from its neighbor, a large amount of sound is
returned to the transducer. The amount of sound returning may be so great
that it is sent from the transducer back into tissues, causing s duplication
of the original structure. The second wave has traveled twice as far as the
first one, the third echo three times as far, and so fourth. The distance
between each successive echo will equal the distance between the original
two interfaces. The second echo and each successive echo parallel the
original interface.

DIAGNOSTIC CONFUSION: Such reverberation artifacts are most

commonly seen adjacent to the bladder anterior wall (figure 33), but also
occur elsewhere in the body in soft tissue as well as fluid; they may mimic
a mass. Reverberations from the anterior surface wall can make a simple
cyst appear complex (figure 33).

Figure (34): Echoes due to reverberations are parallel to the anterior body wall
(arrow) of the bladder
 Figure (35): Reverberations (r) from the body wall may be seen to
extend down into a renal cyst. B. when the scan angle is changed, the
reverberations are no longer seen within the cyst. (c).

RECOGNITION: Reverberation artifacts of this type may occur at some

distance from the original interface (e.g. behind the posterior wall of the
bladder). A second apparent bladder resembling fluid-filled bowel appears
to lie where measurement shows the sacrum should lie (figure 36).
 Mirror Artifacts:
If a sonographic structure has a curved appearance, it may focus and
reflect the sound like a mirror.
RECOGNITION. Mirror artifacts occur most commonly when scanning
the diaphragm. Theoretically, there should be no echoes from the lungs
because they are full of gas, but in fact there is a duplication of the
structures within the liver above the diaphragm in all normal individual
(figure 37). On the left this mirror image can create a false impression of a
pleural effusion because the diaphragm is also duplicated. This artifact
occurs when the patient is scanned in an oblique axis in the coronal
position. Lesions within the liver or spleen adjacent to the diaphragm can
be "duplicated" in the lung.

Benefit. If this mirror image is absent in the lung, it can be deduced

that a pleural effusion is present (see figure 37).

Figure (36): Mirror anifact behind the posterior wall of the bladder with creation of
an apparent cystic lesion posterior to the bladder (arrow)

4-f
 Transducer

Diaphragm

Figure (37): Mirror artifacts. A. In the normal patient there is a mirror image of the
liver tissue above the diaphragm at the site of the lung (arrow). B Diagram of how the
artifact is created. C. When there is a pleural effusion, an echo-free area is seen above
the diaphragm.

4-2
Enhancement Effect:
As the sound beam passes through fluid-filled structures or structure
containing many cysts, it is not attenuated and there is an increase in the
amplitude (brightness) of the echoes distal to the fluid (figure 38).

DIAGNOSTIC CONFUSION. A true pathologic condition may be

obliterated by the increased gain distal to fluid-filled structure (e.g. fibroid
uterus behind the bladder).

BENEFIT. Acoustic enhancement is almost always beneficial and may be

useful in differentiating between solid and cystic lesions, in addition to
aiding the sonographer in seeing deep structures.

Figure (38): Enhancement effect. A. Increased echoes obscure the structures behind
the bladder owing to enhancement of the sound passing through the bladder (arrow). E
Decreasing the gain allows.the uterus to be seen clearly.
Frezonal Zone Artifacts:
The near field of the transducer contains artifactiual echoes.

DIAGNOSTIC CONFUSION: Lesions can be missed if they lie close to

the skin because much of the information in this area is noise (see figure
39).

RECOGNITION: There is little textural information in the first

centimeter or two of the images.
Split-Image Artifact:
A duplicate image occurs when the transducer is placed in the
midline in the pelvis. The curved rectus muscles cause a bending
(refraction) of the sound beam. The beam is bent toward the midline from
both sides of the muscle layer. The system is unaware that refraction has
occurred. The echoes that are returned to the transducer are placed at the
"assumed" distance and direction. The original structure is duplicated
(figure 40). This artifact can occur with a phased array or a linear array
probe, but is more frequent with linear array systems.
DIAGNOSTIC CONFUSION A double image is created. A single sac
can be mistaken for a twin pregnancy, or there may appear to be two
IUDs.

Figure (40): Split-image artifact. A. Scanning transversely in the midline of the

pelvis can create a duplication of the structure, which is situated in the midline due to
refraction. A double image of a Copper 7 IUD is seen in the uterus (arrows). Note the
dimple in the contour of the uterine wall (larger arrow) at the intersection of the two
images. B When scanning away from the midline in the transverse plane, a better
image is displayed. The true configuration of the Cu 7 IUD is seen (arrow). The
dimple has disappeared.
Slice-Thickness Artifact:

When the interface between a fluid-filled "cyst" and soft tissue is

acutely angled, the beam, which is relatively wide (2-3 mm), may strike
both tissue and fluid simultaneous. Low-level artifactiual echoes will be
displayed within the fluid (figure 41).

DAIGNISTIC CONFUSION: Low-level echoes in the posterior aspect of

a cyst may be thought to be evidence of abnormal cyst contents.

RECOGNITION. Echoes are seen at the posterior aspect of the cyst and
develop as the transducer moves from the center of the cyst.

Slice thickness

Artifact echoes

Figure (41): Slice-thickness artifact. A. Echoes in the posterior part of the gallbladder
relate to the slice thickness artifact. The diagram shows the beam intersecting an
oblique segment of the cyst wall B. Sonogram demonstrates low level echoes
apparently in the posterior part of the gallbladder where the gallbladder angle is steep.

4-6
Comet Effect:
A very strong acoustical interface, such as an air bubble, or a metallic
structure, such as a suture, creates a dense echogenic line extending
through the image known as the comet effect (figure 42).

DIAGNOSTIC CONFUSION. The echogenic line may be mistaken for a

real structure.

BENEFIT. The presence of the line indicates a very strong interface and
may allow recognition of metallic structures such as clips.

Figure (42): The comet effect is demonstrated on this longitudinal view of the liver.
At the diaphragm echogenic lines can be seen extending towards the lung (arrow).
 Static Scanning Artifacts:

Lateral Plane Distortion (X-Y axis Miscaiibration, Misregistration, and

Misalignment)
There is marked distortion of the shape of an organ, causing around
structure to look oval when the lateral plane is distorted.

DIAGNOSTIC CONFUSION: organs assume the wrong shape and look

oval rather than round.

RECOGNITION. It is impossible to scan from either side of the abdomen

with a static scanner because the two images will not intersect. Quite
severe X-Y axis distortion may be present before it is obvious on the scan
(figure 43).

Figure (43): Misregistration. A. Transverse view of the right kidney scanning in one
direction. Note gas-filled bowel to the right of the kidney (arrow) and echoes from the
main bang artifact at the skin. B. Scanning the right kidney but angling from the other
direction. Note the distortion of the kidney borders due to misregistration (arrows). C.
There is no distortion of the right kidney. Registration is now in alignment. Note
irregular shadowing due to gas in bowel adjacent to the kidney.
Beam Depth Problem:

Artifacts are present beyond the focal zone of the transducer in the
far part of the field when there are beam depth problems (figure 44). The
echoes in this region are much coarser, and major lesions may be missed if
a long-focus transducer is not used. Because considerable lateral beam
spread occurs, small pinpoint structures appear as transverse 1ine,s.
DIAGNOSTIC CONFUSION: Subtle small lesions may be missed
because of the coarse echogenic structure at depth (e.g. small metastases
in the liver).

Figure (44): The near segment of this liver contains artifactiual information owing to
beam distortion in the frezonal zone (small arrow). Lateral beam spread beyond the
focal zone (large arrow) causes wide echoes with little information.
Compounding:
Often the best way to complete a B-scan is to form numerous small
sector scans to create one overall image. At the junction of the small
sector scans artifact is created because the transducer can be accurately
aligned only rarely (figure 45).
DIAGNOSTIC CONFUSION: The intersection of two sector scans can
be thought to represent a pathologic process.

Figure (45): compound scanning causes this artifact; the image is not aligned (left
arrow).
" ^"; > ^v; A : >;>-*. ^ \ - r

! ! - i .
 Real-Time and Static Scanning Artifacts
Artifacts Caused By Equipment

Artifactiual Noise Reduction:

Equipment can be modified to prevent such interface if it occurs in
the ultrasound laboratory. You may be able to disconnect the interfering
equipment during the scan. Gel warmers are often responsible.

Calibration Problems-Incorrect
Distance Markers Reduction:
Calibration checks should be performed frequently (once a month).
See chapter 49. Measurements should be performed in the center of the
image where calibration is most correct and not at the edge of the video
monitor.

Main Bang Artifact Reduction:

A higher frequency transducer diminishes the problem. Decrease the
near field gain. Use of a stand-off pad will avoid a main bang artifact to
some extent.

Veiling Reduction:
When the veiling cannot be corrected by adjusting the time gain
compensation controls, use only one focal zone.

Absence of Focal Zone Reduction:

Use the focal zone option, and the echoes will appear discrete. Use of
a single focal zone gives better information at a defined depth than when
multiple focal zones are used.

Focusing and Persistence versus Fetal Reduction:

Use only a single focal zone and a little persistence.
Pixel Mismatch Reduction
Use a different transducer. Get the transducer repaired.
Grating Lobes Reduction:
Imaging with a different transducer or changing the patient's position
shows that the supposed echo is artifactiual.

Photographic Artifact Reduction:

Use the focusing system that comes with the transducer at the depth
at which the noise is greatest.

Dust On the Camera Reduction:

Make sure that the camera is dusted frequently.
REDUCTION IN ARTIFACT CAUSED BY

3.1.2
Redaction Of Noise (Technique):
Decrease gain without losing structural information.

Redaction Of transducer Selection problems:

Observe the principles of TGC usage discussed in chapter 4.

Redaction Of Banding:
Use a transducer with a different frequency and focus and alter the
TGC setting.

Redaction Of Contact problems:

Attempt to reposition the transducer or use a transducer with a
smaller face (footprint).

Redaction Of Movement (breathing) :

Ask the patient to hold his or her breath, or utilize the cine loop
control to review the last frames of the scan and freeze when the most
desirable image appears.

Redaction Of Operator scanning Speed:

Use only sufficient pressure to keep the transducer in contact with the
skin.
 REDUCTION IN ARTIFACT CAUSED BY

PATIENT

'Wit*'
 Redaction Of Interactions
The sonographer should attempt to scan around gas or bone,
obtaining scans of the areas below these structures from an oblique angle.

Redaction Of Reverberation Artifacts:

Distinguish such artifacts from real structures by (1) using
transducers of a different frequency, (2) bouncing the transducer on the
abdominal wall and noticing that the second linear structure moves in
exactly the same fashion as the strong echo nearest the transducer, and (3)
scanning the same area from a different angle.

Redaction Of Mirror Artifacts:

Try to scan the same area from another position.

Redaction Of Enhancement Effect:

The sonographer should diminish the overall gain and adjust the TGC
if the condition is pathologic document the increased acoustic
enhancement behind the structure.

Redaction Of Fresnet Zone:

The use of a high frequency transducer the size of the fresnel zones
when scanning superficial structures. Placing the transducer at a distance
from the skin surface by the use ofa stand-off pad moves the area of
interest into the focal zone; the fresnel zone of distortion then lies within
the area of the image occupied by the stand - off pad.

Redaction Of Split - Image Artifact:

To avoid the refraction of the sound beam through the rectus muscle,
scan from a site other than the midline

Redaction Of Slice Thickness Artifact:

Scanning from a different angle shows that there are no echoes
within the area where the slice thickness artifact was seen.

Redaction Of Comet Effect:

Scan from a different angle and the line will either disappear or be
projected onto a different site.
Redaction Of static Scanning Artifacts:
Weekly calibration shows this problem early. Aservice person will be
needed to correct it.

Redaction Of Beam Depth Probe:

These artifacts are unavoidable even with the correct TGC setting if
transducer with a more appropriate focal zone is not used.

Redaction Of Compounding:
Repeat the scan using a smoother technique, preferable using a single
pass. Recognition of the artifact is possible if one observes where the
transducer skin lines join.

When the area of interest is behind a fluid-filled structure many

echoes occur within this area of acoustic enhancement. Several small
sector scans are desirable in such a case. With a single pass only the
structures posterior to the bladder are enhanced. Using several smalls
passes; areas not affected by enhancement can be scanned with gain
increased, creating an overall cosmetic improvement in the image.
*¥ m m

^ ;,; y . 74/ % ,
& ?>****•& ** **' ** ** ********** f • **** *-* * **s*** ** **fr£*** ***y*****
 CT U/S
1. X-Raytube 1- Noise

2. Detectors 2- Calibration problem

3. Operator errors 3- Main bang artifact

4. High-differential metal-brain 4- Veiling artifact

artifacts-streaks 5- Absence of focusing

5. High differential metal -brain 6- Focusing persistence

artifacts streak. 7- Pixel mismatch.

6. High differential air - brain 8- Grating lobes artifact.

artifact overshoot 9- The patient position.

7. Overshoot artifact and partial 10- Dust of the camera in

volume phenomenon cephalagam. photographic.

8. High differential brain-vat 11- Polaroid image artifact.

artifact overshoot.

9. Indexing error artifact.

10. X-ray tube crystal. Alignment

artifact.

1- Technical errors. 1- Noise Artifact

2- Technical errors artifact 2- Transducer selection problem

troticollosed patient 3- Transducer artifact

pantopaque droplets. 4- Contract problem

3- Basil or Impression 5- Movement artifact

6o
 4- Prominent dens and jugular 6- Operator scanning speed.

tubercles 7- Operator pressure

1- Patient motion streak. 1- Shadow.

2- High differential air-skull 2- Reverberation.

artifact streak. 3- Enhancement effect

3- High, differential air-brain 4- Frezonal zone.

artifact streak. Partial 5- Split-image.

volume phenomenon. 6- Comet effect.

4- High differential bore-brain 7- Static scanning

artifact streak. 8- Beam depth problems.

5- High differential bore-brain 9- Compounding.

artifact streak.

6- Patient motion

(A) Pt movement

(B) Cardiac motion

(C) Breathing/ swallowing

1- High density artifact.

2- Poor patient position.

 PARTFOUR

4.1

DATA COLLECTION
AND
DISCUSSION OF RESULTS

62
 Questionnaire onem & ,-

Artifacts in CT Imaging

if ^_JU (V)

Types of CT Artifacts (H.D = High Differential)

A. CT Equipment Artifacts

1-X-Raytube

2- Detectors

3- Operator errors

4- High-differential metal-brain artifacts-streaks

5- High differential metal - brain artifacts streak.

6- High differential air - brain artifact overshoot

7- Overshoot artifact and partial volume phenomenon cephalagam

8- High differential brain-vat artifact overshoot.

9- Indexing error artifact.

10- X-ray tube crystal. Alignment artifact.

B. CT Technique artifact

1-Technical errors.

2-Technical errors artifact troticollosed patient pantopaque

droplets.

3- Basil or Impression prominent dens and jugular tubercles

C. CT patient Artifact

1- Patient motion streak.

2- High differential air-skull artifact streak.

3-High differential air-brain artifact streak. Partial volume

phenomenon.

4- High differential bore-brain artifact streak.

5- High differential bore-brain artifact streak.

6- Patient motion

(A) Pt movement

(B) Cardiac motion

(C) Breathing/ swallowing

1- High density artifact.

2- Poor patient position.

 Questionnaire T w o n ^

Artifacts in Medical Ultrasound

£-Uai

Types of ultrasound Artifacts

A. U/S Equipment Artifacts

1- Noise

2- Calibration problem

3- Main bang artifact

4- Veiling artifact

5- Absence of focusing

6- Focusing persistence

7- Pixel mismatch.

8- Grating lobes artifact.

9- The patient position.

 10- Dust of the camera in photographic.

11 - Polaroid image artifact.

B. U/S Technique artifact

1-Noise Artifact

2- Transducer selection problem

3- Transducer artifact

4- Contract problem

5- Movement artifact

6- Operator scanning speed.

7- Operator pressure

C U/S patient Artifact

1- Shadow.

2- Reverberation.

3 - Enhancement effect

4- Frezonal zone.

5- Split-image.

6- Comet effect.

7- Static scanning

8- Beam depth problems.

9- Compounding.

66
 Interview No. one
CT scan artifacts

1- From your experience in CT investigation what is the common artifacts?

2- Is there any effects at the level of diagnosis caused by artifacts ?

3- What do you think, about problems arise from artifacts ?

4- What is the problems in your opinion that lead to artifacts in your

section ?

5- What is your suggestion and direction to avoid this artifacts ?

6- What is artifacts that caused by patient which represented ?

 Interview No. two
Medical Ultrasound Artifact

l-From your experience in U/S investigation what is the common

artifacts?

2- Is there any effects at the level of diagnosis caused by artifacts ?

3- What do you think, about problems arise from artifacts ?

4- What is the problems in your opinion that lead to artifacts in your

section ?

5- What is your suggestion and direction to avoid this artifacts ?

6- What is artifacts that caused by patient which represented ?

 Analysis of Data collection

Summary of information collected by questioner which shown on tables

with conclusion summary

Table (1)

Participant Number %
sonographer 3 30%
Sonologist 4 40%
Engineers 3 30%

100%

50%
40%
30% 30%

A B C

A sonologists
B sonolgraphers
C engineers

from the table " 1 " above we find that the staff that answered the
questioner consist of sonologists, represent 40% and sonolgraphers
represent 30% and medical engineers represent 30%.

Table (2)

type of equipment Number %

Japanese 8 80%
American 2 20%
Others 2 20%
 100%
80%

50%

20%

A B

A Japanese
B American
C Others

from the table "2" above we find that most of the participant use
Japanese machines which represent 80% and the type of the machines
which are American types and others which represents 20%, this means
the result is mostly dependence on Japanese machines.

Table (3)
type of U.S Equipment artifact.

Type of calibration dust of poloroid noise veiling absence of focusin-g grating pixel
artifact the artifact focusing presistence lopes mismach
camera
number 6 4 1 6 2 1 1
% 60% 40% 10% 60% 30% 20% 10% 10% 10%
Fig (A)

100%

60%

50%
40%
30%
2Q% 10%

A B C D

A calibration + noise artifact

B dust of the camera
C veiling artifact
D absence of focusing
E poloroid + focusing the presetence + grating lobes and pixel mismach

From Table (3) above we find that there are tow peaks can concerning
calibration problem and noise artifact caused by equipment represent 60%
and the lowest cause contributed derived from focusing presistence,
grating lobes and pixel mismach, and ploroid artifact which represent 10%.
For all general view look Fig (A).

Table (4)
Type of U/S Technique artifact

noise transducer tranducer contact movement operator operator focusing

artifact selection artifact problem artifact scanning pressure presistence
problem speed
number 4 8 3 2 1 4
% 40% 80% 30% 30% 20% 10% 40%
 100% 80%

50%
40%
30%
20% 10%

A B D

A transducer selection problem

B noise artifact + operator pressure
C transducer artifact + contact problem
D movement artifact
E operator scanning spped

From Table (4) we find that there is one peak offered by causes of U/S
technique artifact due to transducer selection problem which represent
80%, and the lowest artifact caused by technique is concerning operator
scanning speed which represent 10%.

Table (5)
Type of U/S Patient artifact.

Type of shadow reverbrat- enhancem- frezonal split comet static beam compounding
artifact ion ent effect zone image effect effect depth
problem
number 6 7 3 2 1 5 1
% 60% 70% 30% 30% 20% 10% 30% 50% 10%

n
Fig (A)

100%

70%
60%
50%
50°A

30%
20%

A B C D F

A reverberation
B shadow
C beam depth problem
D enhancement effect + frezonal zone + static effect
E there is no patient artifact
F compound + comet effect ^^^

From Table (4) we find that there is one peak concerning patient
artifact (reverberation) which represent 70% and the lowest caused by the
patient is comet effect and compounding which represent 10%.
Summary of information collected by the personal contact (interview)
which shown on tables with conclusion summary.

Table (1)

types of artifact number %

noise 2 40%
no preparation (gases) 2 40%
probes problem 1 20%

100%

60%

50%
40% 40%

2H%

A B C D

A noise
B no preparation
C probes problem

From the table above we recognize that the most predominant artifacts
is due to noise and gases artifact which represent 40% and the lowers
cause is due to probes problem which represent 20%.

Table (2)
Effect of artifact in the imaging result

types of artifact number %

yes 4 80%
no 1 20%

u
100%
80%

50%

211%

A B

A Yes
B No

From Table (2) above we find that 80% of the participant agreed that
artifact affect the final imaging result, 20% of them agreed that artifact do
not have any effect on the imaging.

Table (3)
Expectation of U/S artifact

artifact may lead to number %

wrong diagnosis 4 80%
not affect in the diagnosis 1 20%

100%
80%

50%

20%

A B

75
 A wrong diagnosis
B No affect in the diagnosis

From Table (3) above we have concluded that 80% of the participant
agreed that artifact lead to wrong diagnosis in U/S imaging while 20% said
that artifact does not affect the final result.

Table (4)
Types of U/S due to cause (by %)

Reason of U/S artifact number %

unknown 1 20%
noise 2 40%
calibration 1 20%
skills 1 20%

100%
80%

50%
40%

20% 20% 20%

A B C D

A noise
B unknown
C calibration
D skills

From Table (4) above we can conclude that the most causes of U/S
artifact in the department is due to noise from the power supply and bad
earthing which represent 40% and the other causes by miscalibration of
U/S unit and skills of the operator, which represent 20% of the total.
Table (5)
Suggestion for the reduction of the artifact in the LJ/S imaging

Directions to avoid number

occurrence of artifact
prepration of pt 40%
equipment earthing 20%
equipment calibartion 20%
operator skills 20%

100%
80%

50%
40%

20% 20% 20%

A B C D

A no preparation of patient
B good earthing
C check calibration
D operator skill

From Table (5) we can conclude that direction to avoid artifact,40% of

them suggested to consider good patient preparation, and 20% suggested
routine calibration of equipment and 20% suggested that better operator
skills.
Table (6)
Artifact due to patient

artifact due to patient number %

preparation of patient 4 40%
un co-operative pt. 2 20%
Movement of the pt. 1 10%
Obese pt. 1 10%
Uncontact probe 1 10%

100%
80%

50%
40%
20%
10% 10% 10%

A B C D E

A preparation of pt.
B un co-operative pt.
C movement of the pt.
D obese pt.
E uncontact probe

From Table (6) we conclude that 40% agreed that artifact are due to pt.
Preparation. 20% suggested that those artifact are due to co-operative pt.
10% suggested that artifact were due to movement of the patient, 10%
have also suggested the cause due to patient obesity and finally 10% have
suggested the cause to be due to uncontact probe.
For details of data collection of questioner look table A,B, and C.
 Table (A)
U/S Equipment artifact
No. Department Participant job Type of equipment Type of artifact
1. government sonographer Japanese 1- calibration problem
2- dust of camera
2. government engineer Japanese 1- calibration problem
2- poloroid artifact
3. private sonologist Japanese 1- noise
4. government sonologist Japanese 1- calibration problem
2- veiling artifact
5. government sonologist American 1-noise
2-calibration problem
3- main bang artifact
4- dust of camera
5- absence of focusing
6. private engineer Japanese 1-noise
2- absence of focusing
3- dust of camera
7. government engineer Japanese American others 1- noise
2- calibration
3- veiling artifact
 4- absence of focusing
5- focusing presistance
6- grating lobes artifact
7- pixel mismach
8- dust of camera
9- noise
8. private sonographer Japanese 1 - noise
9. government sonographer others 1- calibration
10. government sonologist Japanese 2- veiling artifact

8o
 Table (C)
U/S Patient Artifact
No. Department Participant job Type of equipment Type of artifact
1. government sonographer Japanese 1 - not found
engineer Japanese 1 - no found
2. government sonologist Japanese 1- reverberation
2- frezonal zone
3. private sonologist Japanese 1- shadow
4. government 2- reverberation
3- beam depth problem
sonologist American 1- enhancement effect
5. government 2- split image
3- static scanning
engineer Japanese 1- shadow
2- reverberation
6. private 3- enhancement effect
4- frezonal zone
5- static scanning
7. government 6- beam depth problem
7- compounding
engineer Japanese American others 1- shadow
2- reverberation
 3- enhancement effect
4- frezonal zone
5- split image
6- comet effect
7- static scanning
8- depth problem
8. private sonographer Japanese 1- shadow
2- reverberation
9. government sonographer others 3- beam depth problem
10. government sonologist Japanese 1- shadow
2- reverberation
1- shadow
2- reverberation
3- beam depth problem

82
 Table
U/S Technique Artifact
No. Department Participant job Type of equipment Type of artifact
1. government sonographer Japanese 1- not found
2. government engineer Japanese 1- transducer selection problem
3. private sonologist Japanese 1- noise artifact
4. government sonologist Japanese 1- transducer selection problem
2- movement artifact
3- operator pressure
5. government sonologist American 1 - noise artifact
2- transducer selection problem
3- transducer artifact
4- contact problem
6. private engineer Japanese 1- transducer selection problem
2- transducer artifact
3- operator pressure
7. government engineer Japanese, American, others 1-noise artifact
2- transducer selection problem
3- transducer artifact
4- contact problem
5- movement artifact
6- operator scanning speed
7- operator pressure
8. private sonographer Japanese 1-noise artifact
2- transducer selection problem
9. government sonographer others 1- transducer selection problem
10. government sonologist Japanese 1- transducer selection problem
2- contact problem
3- operator pressure
 Table (1)
CT Equipment Artifact

Types of CT artifact Number %

1-X-Raytype 5 50%
2- Detectors 6 60%
3- Operators errors 4 40%
4- High differential metal brain artifact streak 8 80%
5- High differential air brain artifact over shoot 6 60%
6- Overshoot artifact and partial volume phenomena cephalogram 4 40%
7- high differential brain-vat artifact overshoot 1 10%
8- Indexing error artifact 1 10%
9- X-Ray crystal. Alignment artifact 2 20%

90%
80%
70%
60% 1—1
50%
40%
30%
20%
10%
n n
6 7 8

Key:
1- X-Ray tube
detectors
operator errors
high differential metal-brain artifacts streak.
High differential air brain artifact over shoot
Overshoot artifact and partial volume phenomena cephalogram
high differential brain-vat artifact overshoot
Indexing error artifact
X-Ray crystal. Alignment artifact

From the table above we have recognized that the most predominant
artifact is due to " high differential metal brain artifact streak "represents

8 $ •
80% the second peak is detectors artifact and it represents 60% the lowest
contribution came from " high differential brain vat artifact overshoot "
and indexing error artifact represent 10% for both of them.

Table (2)
Technique Artifact

type of equipment Number %

Technical errors 3 30%
1 - Technical errors 3 30%
2- Technical errors artifact troticollosed pt. pantopaque 2 20%
droplets
3- Bast or impression prominent deus and jugular
tubercles
1 10%

30%

20%

10%

1
Key:
1- Patient motion streak.
High differential air-skull artifact streak.
High differential air-brain artifact streak. Partial volume phenomena.
High differential bore-brain artifact streak .
5- patient motion.

From the table above we can recognize that the most predominant
artifact is technical errors and it represent 70%, the second peak is
technical errors artifact troticollosed pt. pantopaque droplets and represent
20%, the lowest contribution come from Basil or impression prominent
deus and jugular tubercles represent 10%.
 Table (3)
CT Patient Artifact

Type of artifact number %

1- Pt. Motion streak 5 50%
2- High differential air-skull streak. 6 60%
3- High differential bone-brain artifact streak. Partial volume 4 40%
phenomena.
4- High differential bone-brain artifact streak. 4 40%
5- Pt. Motion 8 80%

80%
70%
60%
50%
40%
30%
20%
10%

Key:
1- Patient Motion streak.
2- High differential air-skull artifact streak.
3- High differential air-brain artifact streak. Partial volume phenomena.
4- High differential bore-brain artifact streak .
5- patient motion.

From the table above we can recognized that the most predominant
artifact pt. Motion and represent 80% the second peak is high differential
air-skull artifact streak represent 60% the lowest contribution come from
high differential bone-brain artifact streak. Partial volume phenomena and
high differential bone-brain artifact streak represent 40% for both of them.

89-
Summary of information collected by personal contact which is shown
on tables with conclusion summary
Most probable artifacts in CT image cause by table one

Types No. %
1- Blurring of the image " streaks " 3 70%
2- Calibration problem 1 20%
3- High atomic number material in teeth 1 10%

100%

70 %
70%

40% II
40%

10%
III 10%
lit
HI

A B C

Key:
A Blurring of the image
B calibration
C High atomic number material in teeth

From Table we can conclude that the most predominant artifacts are
streaks which represent 70%, the second peaks formed by patient motion
which represent 20%, the lowest artifact source were due to high atomic
number material which represent 10%.
Table (2)
Change in image information

Types No. %
1- Yes 4 80%
2- Yes
3- Yes
4- Yes
5- No. 1 20%

100%
80%
80%

20%
20%

A B

From the table above we can conclude that most artifacts due to the
level of diagnosis which represent 80% and the lowest cause which is
about 20% considered not having any change in diagnosis.

Table (3)
Expectation of Artifact in image result

Types No. %
1- Unknown 1 20%
2- Wrong diagnosis 3 60%
3-
4- Ci

5- Not effect to the diagnosis 1 20%

 60%
60%

20% 20%
20%

A B C
Key:
A Unknown
B Wrong diagnosis
C Not affect to the diagnosis

From the table above we can conclude that 60% of the faults lead to
wrong diagnosis, 20% were due to unknown causes and only 20% which
did not have any affect on image information or diagnosis.

Table (4)
Reasons of faults in CT image
Types No. %
1- Due calibration of CT 1 20%
2- Use of CT control 2 40%
3- Due motion of pt. 2 50%
4- Due 3 rd generation 1 10%

60%

50% 50%

20% 20% 20%

20%
10%

A B C D
 Key: of table (4)
A Due contribution of the CT unit
B Use of CT control
Due motion of pt.
rd
D Due 3 generation of CT

From the table above we can conclude that the most predominant
artifacts due to motion due to pt. Which represent 50%, the second peaks
is due to use of apparatus which represent 20%, the third peaks is due to
wrong calibration which represent 20% and finally the lowest contribution
were caused by third generation which represent 10%.

Table (5)
Suggestion for reduction of artifacts in CT image

Types No. %
1- Instruction to pt. To put away all F,B 2 40%
2- Equipment maintenance. 2 40%
3- Sedation. 2 20%

40% 40% 40%

20%

A B C

Key:
A Instruction to the pt. To put away all F.B
B Equipment maintenance
C Sedation

From the table above we have concluded that the most predominant
artifacts are due to equipment calibration (40%), 40% is also found due to
lack of communication with patient and 20% due sedation.

9/
Table (6)
Artifacts due to patient

Types No. %
1- Streak 5 100%
2- «
3-
4-
5-

100% 100%

From the above table (6) we have concluded that streaks took 100% of
the image artifacts.
 5.1

OF CT. AND ULTRA SOUND

Quality Assurance of C.T:
Quality assurance may be defined as the testing of the system to
ensure consistency and acceptability of performance.

There are many tests available to assess the performance of the

scanner, some of which are carried out by the manufactures, although
departmental staff should be able to regularly monitor the equipment
without any loss of patient throughput.

The amount of quality assurance required depends on the type of

work undertaken by the scanner. A detailed quality assurance programme
be necessary if radiotherapy planning and research work is undertaken, but
a less intensive programme will be required if only general work is
undertaken.

The amount of quality assurance also depends on the type of system.

Systems, which are, stable and require minimum servicing will not require
a detailed quality assurance programme, but a newly installed scanner
should be repeatedly tested for a given period of time. If the results of
these checks are satisfactory a reduction can take place in the quality
assurance, which can then be undertaken by the service engineer.

However, it should not be taken for granted that a newly installed

scanner, purchased for its reputation of stability and reliability will be
stable in every aspect of its performance. If two identical scanners are
situated in adjacent hospitals or even within the same department each
scanner will develop its own "character" and idiosyncrasies. Thus it is
good policy to keep the same service engineer who can then learn the
idiosyncrasies of the one system.
 Quality assurance is carried out by using a selection of phantoms
from the variety available. These phantoms come in many different forms,
i.e. circular or body shaped, and are used to test various parameters.

a. Single structure phantoms are made from polystyrene, which is

filled, with water. This type of phantom is used to test a specific
parameter.

b. Composite phantoms are made from several materials with

known accurate CT numbers. These phantoms may allow an
interchange of "plugs" of varying materials to be either inserted or
removed.

c. Calibration phantoms are used to check the accuracy of CT

numbers. If the CT numbers are not within the manufacture's
specification calibration scans are undertaken using these
phantoms. The information obtained is used to reconstruct a;
subsequent tests or patient scans.

There are varieties of tests that can be carried out using the above
phantoms, which include:

(1) CT number of water.

(2) kVp response.

(3) Spatial resolution.

(4) Low contrast resolution.

(5) Radiation dose.

(1) CT number of water:

This test should be carried out daily using the same phantom and a
consistent technique. For example, 120 kVp, 200mA3 seconds with 10mm
collimation on a standard algorithm using a 256x256 matrix.

If this is routinely performed every morning it will monitor the

system for linearity of CT number. If the CT number changes, it may
indicate a problem with the tube, kVp or mA. This test also ensures that
the processing image display and archiving facilities are correctly
functioning. All test scans should be kept for comparative studies.

(2) kVp response:

A test using a composite phantom may be carried out weekly to

check the system's kVp response to materials other than water.

(3) Spatial resolution:

Spatial resolution is the ability of the system to detect the separation

of adjacent closely spaced objects. A spatial phantom is used, and by
applying a constant radiographic technique, for example, 120 kVp,
200mA, 3 seconds, 10mm collimation and standard algorithm, the
resolving power of the scanner can be monitored.

(4) Low contrast resolution:

An interchange of "plugs" of varying CT number are used with the

composite phantom to check the sensitivity of the scanner.
(5) Radiation dose:

The radiation dose from the scanner should be checked fortnightly or

when a kVp calibration has been undertaken, or whenever there is a tube
change. A polystyrene phantom with holes for the insertion of
thermoluminescent dosimeters is used. A series of scans should be made
using the body and brain technique factor.

There are several other tests, which should be routinely conducted on

the system, including: (1) Table indexing. (2) Patient alignment lights. (3)
Hardcopy camera.

(1) Table Indexing:

For reasons already mentioned, it is essential to be able to position

the table accurately. The table drive mechanism is subject to wear and tea
therefore, tables accuracy should be checked using phantom with a pin
inserted at a specific point. A scan is taken, the table then table indexed
out of the aperture as finally returned to the first scan position. The table
should re-align accurately, a second scan is then taken, which be identical
to the first one. Many gantr have numerical readout showing the distance
(mm) that the table has traveled.

(2) Patient alignment lights:

The patient alignment lights should be checked weekly at the time as (1).

(3) Hardcopy camera:

Shutter exposures and gray scale should be routine checked.

 Many of the above tests will be carried out by the service engineer as
part of the servicing arrangement. However, that operator should carry out
independent tests ensuring that machine is regularly monitored.

As well as the general mechanical service it is essential that the

scanner is kept scrupulously clean. Any spillages during scanning session
should be cleaned up immediately.

Quality Assurance of U/S:

To benefit from ultrasound as diagnostic aid, one must be fully aware
of its drawbacks and limitations, as the interpretation of the picture can
other wise give misleading results. Therefore only through knowledge of
how to avoid some of the most obvious pitfalls will enable the user to
obtain maximum benefit from the equipment.

In the following, a few of the most common reasons for impairment

of picture quality are dealt with using the knowledge gained in the theory
chapter.

Electronic Circuit:

Vast number picture artifacts may originate from the electronic

circuits involved in the generation and processing of the ultrasound. Many
of these artifacts can be readily recognized, andonly some of the most
significant artifacts originating from the restriction in the design and
operation of well-engineered ultrasound equipment are discussed here.

Noise Artifacts:
A common source of spurious echoes in any ultrasound equipment
for medical diagnostics is the inherent noise generated in the electronic
circuitry. It is generally the noise level of the input amplifier alone. Which
limits equipment performance with respect to low-level signals. With
doppler equipment, however, distortion and spurious modulation will also
have a considerable limiting effect with respect to low-level performance.

The so-called signal-to-noise ratio is given by the ratio of useful

signal to noise at any echo amplitude:

Signal-to-noise ratio = useful signal amplitude

Noise amplitude
Noise is no problem in the near field of the transducer in non-doppler
systems. As receiver amplification here is moderate. Further away from
the transducer, where the compensation circuit amplification is high, the
input noise may become excessive. To obtain a picture of diagnostic
significance the signal-to-noise ratio should not be less than 3dB (1.4
times) at any displayed signal amplitude.

Quantisation, i.e. the division of an analogue signal into a finite

number of amplitude group, is a source of noise peculiar to digital storage
systems.

Detection Thresholds:
It is quite possible that the minimum signal, which the system can
process, is several dB above the noise level. If this is the case, the useful
dynamic range will be less than the stated signal-to-noise level. If the
minimum signal which could be processed is 8 dB above the noise level,
and the signal-to-noise ratio is 10 dB with a particular echo signal, this
signal can only decrease a further 2 dB before it is no longer registered. A
common reason for this might be deliberate rejection effect at an echo
envelope detector.
Storage:
Conversion circuits for gray-scale displays should not added all the
amplitudes registered for any given point on the display, because this will
not allow several scans of the same structure in one single store operation
without blurring the picture excessively with analogue and causing
overflow with digital storage. Thus last-value-write or speak-hold types of
circuits should be used avoid artifacts.

Digital storage systems have the problem of quantisation noise

already mentioned. Furthermore, the quantisation will also give rise to an
additional threshold effect at the lowest signal levels, which is not
experienced with analogue systems. With a number of gray-scale values
exceeding some 12-14 respect to both brightness position and threshold
effects can generally be neglected.

Compensation Setting:
The compensation should be set to minimize the number of artifacts,
but at the same time giving the maximum detail in the representation of
the examined tissue. A reasonable initial setting will normally be given in
the instruction manual for the particular equipment. With digital systems
automatic resetting to this position will often occur at switch-on. This
setting can then be modified at will.

Care should be taken not to get artifacts from transducer ringing (too
high an initial gain) and amplifier noise or spurious echoes (excessive
final gain). Too low gain settings should also be avoided, as this will
aggravate possible threshold and noise problems by not utilizing the
maximum useful-signal handling capacity of the equipment.

\QQ
Gray-Scale Adjustment:

Incorrect setting of the gray-scale conversion circuit can lead to

severe picture artifacts due to the factors mentioned above.

If the system has a storage system with accessible controls, efforts to

improve a given scan should not be attempted by adjusting the
amplification and background level of the circuit. Once the optimal setting
for this part of the system has been found, the contrast range of the
converter, which is quite small compared to that of the human eye, will fit
the dynamic range of the electronic processing circuit optimally.

Further adjustments will cause the gray-scale range to fall outside the
dynamic range of the processing circuit output, making the picture either
too bright or too dark. In either case, the usable gray-scale part of the
display is reduced as a result of either too small a signal or overload of the
conversion circuit, and the gray-scale information obtainable is reduced.

Scanning Rate:

When scanning moving objects in the body with a static display, the
picture will not be very sharp, and may be almost useless as far as the
moving objects are concerned except for such moderately moving
structures as the aorta. This is due to the very long scanning time, i.e.
effectively an extremely low scanning rate compared with the rate of the
movement of the objects. When using a dynamic scanner, the problem no
longer exists if the scanning rate is sufficiently high. A scanning rate of
more than 16-20 picture updates per second will, dependent on scanning
and display system generally be sufficient to avoid artifacts.

lot
 Dependent on the particular structure studied, the effect of too low a
scanning rate with a dynamic scanner may be far worse than the blurring
caused by moving objects with the static display systems. Besides the
unavoidable reduction of sharpness, the shape of the moving structure and
its rate of movement can be heavily distorted due to a stroboscopic
phenomenon known as aliasing. What actually happens is that the system
is unable to differentiate between successive movement cycle, and is
displaying the information more or less at random so that both the shapes
and the movement of the moving hinge is heavily distorted. It should be
emphasized, that this is an extreme case unlikely to occur with normal
scanners, except when scanning rapidly moving heart valves.

Selecting the Transducer:

Resolution:
The effective diameter of the beam is dependent on the diameter of
the piezoelectric crystal. The gain level of receiver will also affect the
apparent effectively beamwidth since with a low gain level, only the
highest-amplitude portions of the beam will give detectable echoes.

The lateral resolution of the transducer is determined by the

beamwidth, because an echo from a reflecting surface will be registered
all the time it is inside the beam, i.e. points closer together than the
beamwidth cannot be resolved. Poor lateral resolution makes it difficult to
discriminate between cystic and solid structure, since the picture will be
blurred.

If the transducer pattern has many significant side-lobes, as might be

the case with transducer of small size compared to the wavelength, ghost-
echoes can occur. With pulsed ultrasound, the effect of the side-lobes will

1oZ
normally be reduced as compared to a steady-state situation, as many of
the interference causing the steady-state side-lobes will not have time to
arise.

Internal Echoes:

A badly designed or engineered transducer can give may spurious

reflections which have nothing to do with the tissue structures being
scanned. Several factors may cause this.

Insufficient backing can give reflections from directions other than

that of the tissue, which will be displayed as if they were actually situated
in the scanning direction. The backing can be insufficient in respect to
both absorption and to transmission from the crystal into the sole material.

Impedance differences between the transducer itself and the

transducer coating will result in poor transmission and false echoes. This
result may also happen with well-designed transducers if the sole material
has been loosened, e.g. after mechanical abuse.

Geometric Distortion and Sound Velocity Variations:

Velocity variations of ultrasound in tissue are generally small. The

only major velocity changes occur at boundaries between soft tissue and
bone, and at boundaries between tissue and artificial heart valves.

The effect of the increase in sound velocity is that structures behind

the high velocity structure will seem to be closer to the transducer than is
actually the case, and that angular distortions will arise, so that the
assumption of a straight path by the electronic circuits is no longer correct.
 Fast layers may also give rise to annoying geometric distortion, as
they can act as unwanted acoustical lenses in the tissue.

Spurious Reflections:

Spurious reflections can occur from inside of a badly designed or

engineered transducer, but are more likely to arise from ultrasound pulses
wandering back and forth between a heavily reflecting boundary and the
transducer. This phenomenon is popularly known as re-reflection and is
quite likely to occur when borders between areas of greatly differing
specific acoustic impedance are scanned.

Re-reflections may arise from the strong echoes from the ribs (bone),
when not scanning in the intercostal spaces. They will usually be
accompanied by some sort of shadow effect, when trying to find a
compromise between a high gain to avoid the effect of the attenuation and
strong reflections of the ribs, and the low gain preferable to dimmish the
re-reflections.

The so-called "rain" that can occur close to the anterior bladder wall
when scanning the uterus through the full bladder is also most likely to be
re-reflections.

Granulation:

Granulation of an image, or acoustic speckle, can occur with highly

directional sources such as those used in diagnostic ultrasound. It means
that structures which are known to be continuous, e.g. the myocardium,
are displayed on the on the ultrasound image with a granular appearance.

Acoustic speckle is dependent on the relative positions of the

transducer and the structure being studied, and the speckle spots diminish
in size with increasing resolution. Static B-mode systems and real time
systems with multiple simultaneously active transducers operated in
compound mode produce less speckle, because many single beams from a
variety of positions are used to image the same structure.

Air-Field Structures:

The effect of air in the body structure is that the ultrasound is almost
totally reflected. Thus no structures behind a lung or any other internal
cavity filled with air can be seen. However, it is to some degree possible
to overcome such problems by scanning from different positions.

Shadows and Bones:

Shadows behind a heavily reflecting and/or attenuating structure can

easily arise when scanning. This problem is often overcome by scanning
obliquely into the hidden area. However, it should be noted that shadows
might also yield valuable information, e.g. shadows behind a gall stone.

In theory, bone can give rise to five possible causes of picture

artifacts. These are increase in sound velocity; increase in attenuation,
considerable reflection, strong reflections and the shadow effect just
described.

The strong reflections and the increased attenuation of ultrasound by

bone reinforces the limitations caused by the increased velocity and the
shadow effect, and makes it almost impossible to penetrates bony
structures, as very little energy will be left for detecting tissue structures
behind them. Should the bone be penetrated, the large velocity refractions
given rise to an angular distortion effect.

Classifications and Dehydration:

 Classification of tissue structures will be lead to severe attenuation
and scattering of the ultrasound beam from the transducer. The main effect
of dehydration is also increased scattering in the tissue.

Due to the spurious echoes from the radiated spherical waves, it will
be difficult to discriminate between cystic and solid structures. Generally,
the picture will look blurred.

Fat:
Fat gives unwanted diffraction and high attenuation of the ultrasound,
making it difficult to obtain echoes underneath the far layer, if this is
abnormally thick. There is also a tendency to get scattering in fat layers.

Fat has largely the same effect as calcification and dehydration, and
makes it difficult to discriminate between cystic and solid structures.
Generally, the picture will look blurred.

p6
 PARTins

5.2

CONCLUSION AND RECOMMENDATION

 CONCLUSION

From this study we have reached the following conclusion :-

Imaging artifacts in both X-Ray CT and Ultrasound Image are due to the
following:

1. Equipment artifacts.
2. Technique artifacts.
3. Patient artifacts.
Each of the above fault contribute by same way or another to the
detraction of image quality and hence would lead to retake of image.
However, from the analysis of the data collected for this research,
which was conducted by questioner and personal interviews we did find
that most of the artifact in ultrasound is due equipment calibration
problems and noise interference ( from radio and improper earthing 60%).
While artifacts from computed tomography is due to high differential metal
brain artifacts etc. (80%).
From the other hand, the occurrence of technique artifact in the U/S
is due transducer selection problem (80%) where as in CT technical errors
artifact is about (30%) patient artifacts in ultrasound is only by
reverbration which is about 70% while in CT is patient motion which is
about 80%, other patient problem artifacts due to patient preparation is
40% while patient movement is 70%.
Find to reduce the pressure of artifacts in image the operator should
have good command of the control console and he/she should the meaning
of all keys in addition to the better patient preparation during the exam as
well effective patient communication and use of immobilizing devices.
 RECOMMENDATION

As regard to imaging artifact or indirectly affecting the final image

result, we recommend the following :

1. Quality control must on inseparable programme for both system

CT/U/S so as to trouble shoot and prompt diagnosis of imaging
familiars before it became serious as to affect the final image
quality.
2. There should be routine preventive maintenance by the equipment
engineers according to a pre-planned maintenance schedule.
3. When preparing patient for either CT or Ultrasound imaging
technologists should make sure that patients are artifact free i.e.
free metal buttons, etc.
4 In the teaching curriculum for radiographs there should be
inclusion of a complete teaching unit dealing with imaging
artifacts in CT and Ultrasound.
5. Continuing inservice education staff orientation and professional
development must be an on going process for all staff
technologists.
6. In the case of Ultrasound imaging there must be proper
connection of the earthing continuity with the imaging unit as well
as to isolate the Ultrasound unit from any source of
radiofrequency or the meanness of any power source to avoid
infrequencies between the two systems as not to effect the real
time image on the TV monitor during imaging sessions.

/of
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Appendix
Key to Appriviation of items

U/S: Ultrasound

CT: Computed Tomography

CAT: Computerized Axial Tomography

TGC: Time gain compensatory

EMR: Electromagnetic Radiation

ill