01 White Paper No.

03/2010

The first fully-digital C-arm.

21st century mobile X-ray imaging.

Ziehm Imaging’s product strategy is heav- Monitor

ily focused on the continuous enhance-
ment of mobile C-arm functionality, mo-
D/A
bility and network capabilities. Innovation Image processing/
milestones include the replacement of storage
A/D
conventional electron-based image in-
tensifiers with digital flat-panels. Début- Camera
ing at RSNA 2001 (annual congress held
Image intensifier
by the Radiological Society of North
America) in Chicago, Ziehm Vision FD’s
fully-digital C-arm was developed Patient
specifically for applications demanding
the highest levels of image quality and
precision. These include 3D CAS (Com- X-ray generator

puter-Aided Surgery) and angiographic

applications. The highly dynamic and
Fig. 1: Conventional video chain
distortion-free images are the foundation
for a 3D reconstruction procedure, spe-
cially developed by Ziehm Imaging. And Conventional video chain – image
thanks to the elliptical path of the detector intensifier with CCD camera
and the X-ray tube, optimum image geo- The electron-optical X-ray image intensifier is an
metry is ensured – regardless of the angle. evacuated metal/glass tube which consists of
four basic elements. These are the input screen
In order to be able to fully understand the signifi- (fluorescent screen and photocathode), the elec-
cant benefits of the digital flat-panel detector, it is trostatic lenses (electrode voltage 30 kV), the
necessary to describe the characteristics and accelerating anode and the output screen (fluo-
functional principles of conventional imaging sys- rescent screen). The individual components of the
tems first. Several consecutive conversion steps image intensifier are illustrated in Fig. 2. The
are required for generating usable image infor- fluorescent input screen (with a layer consisting
mation from X-ray photons. This conversion sys- of caesium iodide doped with natrium – CsI:Na)
tem (Fig. 1) comprises the analog X-ray image absorbs the X-ray photons and converts their
intensifier, a tube camera or alternatively a CCD energy to light photons. These light photons hit
(charge-coupled device) camera, an analog/ the photocathode and are emitted from there as
digital converter and a digital/analog converter, photo electrons, proportionally to the brightness
image processors and a TV monitor. of the input screen. A high potential difference (up
02 White Paper No. 03/2010

be emitted. Due to their strong acceleration, the

electrons produce approximately 50 times as
many light photons on the output screen. [Curry].
A tube camera consists of a vacuum tube having a
diameter of 2.5 cm and a length of approx. 15 cm
which is surrounded by control coils. Immediately
behind the glass input window, the radiolucent
conductive layer and the light-sensitive semicon-
ductor layer are located. The semiconductor layer
is scanned row by row by the electron beam which
can be fine-tuned by the control coils (Fig. 3).
Depending on the brightness at each scanned
Fig. 2: Conventional image intensifier position, a higher or lower signal electricity is
generated and transmitted as an analog video
signal via the analog/digital converter to the im-
age processing system and then further on to the
monitor. [Curry] The tube camera was used in
mobile C-arms until about 1996 (Fig. 4).

Conventional video chain – image

intensifier with CCD camera
Fig. 3: Schematic representation of a
tube camera Since the tube camera featured higher dynamics
and a better resolution than the CCD camera (at
least according to its specifications), the signifi-
cant benefits offered by the latter (in addition to
its lower price) could only be explored empirically.
Yet it was possible to compensate the theoretic
limitations reflected in the CCD camera‘s techni-
cal data by means of electronic signal amplifica-
tion to such an extent that the resulting image
quality finally surpassed that of the tube camera.
On modern C-arms equipped with 1 k systems,
approx. 1 million photodiodes form a field of only
7.68 mm x 7.68 mm in the silicon-based video chip
(Fig. 5). A single photodiode is as small as
Fig. 4: C-arm with tube camera 7.5 μm x 7.5 μm. A CCD camera has the ability to
store electric charges in cells (photodiodes) and
to 30 kV) which is applied between the photocath- to transport them after a row-by-row readout
ode and the accelerating anode pulls the elec- process – at a rate of max. 25 frames per second
trons away from the photocathode very quickly. – as an analog signal via the analog/digital con-
The electrostatic lenses drive the electrons flying verter to the image processing system. The dis-
from the cathode to the anode precisely to the tribution of those charges to the individual cells
fluorescent output screen. The electrons which and the electrons stored in them represent the
hit the output screen again cause light photons to stored image. Compared to tube cameras, CCD
03 White Paper No. 03/2010

above is mature, significant improvements can no

longer be expected. This technology level exhibits
some typical characteristics. One example is the
distortion caused by the terrestrial magnetic field
or other, artificially-created magnetic fields, on
the image intensifier. Only a technology leap to
fullydigital flat-panel detectors equipped with
highly-integrated solidstate electronics will bring
Fig. 5: CCD camera video chip about substantial further development and im-
provements in image accuracy and dynamics.

The use of digital flat-panel detectors

on mobile C-arms
CCD camera The aim was to reduce the number of conversion
housing
steps required for imaging to a minimum, while at
the same time keeping the amount of losses and
errors involved as small as possible. An imaging
chain realized with a digital flat-panel detector is
much more compact and simple than a conven-
tional one, as can be seen already from its graph-
Fig. 6: Ziehm Vision with CCD camera ical representation (Fig. 7, as opposed to Fig. 1).
Before explaining the detector technology used
cameras require much less space, since the coils on fully-digital C-arms in detail, we should briefly
which control the electron beam are no longer differentiate the possible concepts with regard to
needed [Curry] (compare sizes of the image in- their usability. Basically, there are two different
tensifier housings in Fig. 4 and Fig. 6). In addition, types of digital detectors: ones that work with di-
they respond more quickly and more directly and rect detection of the X-rays, and ones that work
are less sensitive to overexposures. We have ex- with indirect detection. With a direct detector, the
plained how X-ray photons are converted first X-ray photons which hit an amorphous selenium
to visible light and subsequently to accelerated (a-Se) plate are directly converted to electron-
electrons before they hit the output screen of the hole pairs (Fig. 8). In the selenium layer, a bias
image intensifier. The emitted light photons are voltage drives the charge carriers above a pixel
output by the camera as an analog signal, which electrode into the pixel to be collected. With direct
is then converted again by an analog/digital con- conversion, there is no light scatter. A-Se detec-
verter prior to storage or image processing. If an tors therefore distinguish themselves by an
analog CRT monitor is used for image display, excellent Detective Quantum Efficiency (DQE) of
another digital/analog conversion is required. up to 65 % and an extremely good contrast reso-
Each of these conversion processes implies a lution. However, this technology has one feature
loss of the original image information, thus de- which impedes its use in mobile systems. The
creasing the obtainable image quality. In a con- different expansion coefficients of glass and sele-
ventional video chain, image quality depends on nium produce tension cracks at temperatures
several components, whereby the weakest ele- below 10 °C and above 70 °C. In addition to that,
ment determines the overall performance of the the selenium layer loses its amorphous structure
entire chain. Since the technology presented at temperatures above 70 °C and adopts an irre-
04 White Paper No. 03/2010

TFT flat-screen
versible crystalline structure. Only stationary
radiological equipment with its permanently
available mains voltage allows for continuous
control of the permissible temperature range,
Image processing/
storage thus guaranteeing disturbance-free operation at
reasonable costs. With indirect detection (Fig. 9),
Digital flat-panel the X-ray photons hit a scintillator consisting of
detector
caesium iodide doped with natrium (CsI:Na),
which converts them to light photons and sends
them to the sensor matrix (photodiodes) made of
Patient amorphous silicon (a-Si) which lies behind it.
Since silicon is not sufficiently sensitive to X-ray
photons, the CsI scintillator is required for energy
conversion (similar to its use in an image intensi-
X-ray generator fier). The individual sensors of a cell are activated
via an address line, and the resulting X-ray profile
is scanned row by row and transmitted to the im-
Fig. 7: Video chain with digital flat-panel age processing system. Fig. 10 shows the func-
detector tional principle in a simplified way. Since this
detector concept has a higher resistance to envi-
ronmental influences, it is also suitable for use in
mobile C-arms.

Integration of the a-Si detector into

the C-arm

For this reason, Ziehm Imaging decided to inte-

grate an a-Si detector into the Ziehm Vision – the
C-arm model which was especially designed for
Fig. 8: Functional principle of an a-Se detector high-end applications. After just 6 months of de-
velopment, the first C-arm equipped with a digital
flat-panel detector – the Ziehm Vision FD (Fig. 11) –
was ready to be presented to the public at the
RSNA 2001 (Radiological Society of North Ameri-
ca) in Chicago. The detector is available with pixel
area options of 19.8 cm x 19.8 cm or 30 cm x 30 cm,
containing 1024 px x 1024 px or 1536 px x 1536 px
with a size of 194 μm each. The storage depth is
14 bits, thus allowing the display of up to
Fig. 9: Structure of an a-Si detector with 16,384 levels of grey. With a maximum frame rate
CsI scintillator of 25 frames per second, more than 30 million
pixels per second are read out and processed in
the highly-integrated electronics using a bus width
of 14 bits, and are then displayed on the TFT flat-
screens at an image quality which could not be
05 White Paper No. 03/2010

obtained before (Fig. 12). The a-Si detector is able

to capture the object information with practically
no losses. An outstanding image quality, yet
achieved with less dose and hence reduced radia-
tion exposure for patients and doctors, is the
result of this revolutionary imaging chain.

Efficiency and significant benefits

As the efficiency of such a detector is determined Fig. 10: Functional principle of an (a-Si)
by a large number of inter-dependent parame- flat-panel detector

ters, its characteristics can be described using a

variety of methods. But surely the best method
consists in choosing variables which correlate
with the interests of the user and are related to
visible image quality. For such a user-focused as-
sessment, the Detective Quantum Efficiency
(DQE) and the dynamic range as well as a qualita-
tive examination of the distortion prove to be the
most suitable parameters. The first one of these
parameters – the DQE – describes the efficiency
with which the image information is transmitted
between entering and leaving the detector. A de-
tector with a DQE of 1 or 100 % does not have any
losses during information transfer, hence repre- Fig. 11: Ziehm Vision FD – the first mobile
senting the theoretical optimum. The DQE is de- C-arm with a digital a-Si detector
fined as the quotient of SNROut (signal-to-noise
ratio at the detector output) and SNRIn (signal-to-
noise ratio at the detector input). The detector
used in our new model reaches a DQE of 0.65
or 65 %, which is a very good value. The higher
the detective quantum efficiency, the better the
image quality at a given dose. In other words: by
increasing the detective quantum efficiency, it is
possible to achieve a dose reduction while the im-
age quality remains constant. With rising spatial
frequency (measured in line pairs per millimetre
– lp/mm) and a high MTF (Modular Transfer Func-
Fig. 12: Ziehm Vision FD with monitor cart and
tion), any noise in the image increases, thus TFT flatscreen monitors
resulting rather in a degeneration of the image
quality that is visible by the user. By using the DQE
as a variable, these conflicting goals are avoided Visualising high-density anatomic elements with
and the behaviour is quantified by a single low intensity (high absorption of the X-ray pho-
function. The ability to visualise small and low- tons) and low-density elements with high inten-
contrast objects is thus qualified by the DQE. sity (low absorption of the X-ray photons) together
06 White Paper No. 03/2010

in one X-ray image in a clearly distinguishable operation of mobile C-arms – the operating
way has always been a prime concern in X-ray theatre – is usually not shielded against the elec-
diagnostics. This has now become possible thanks tromagnetic radiation emitted by MRI equipment.
to the high dynamics inherent in digital detector With the Ziehm Vision FD it is possible to generate
technology. Human anatomy provides many ex- completely distortion-free images of the human
amples where it is necessary to display very body irrespective of any electromagnetic influ-
bright and very dark areas simultaneously. Fili- ences, be they of natural or artificial origin. Proof
gree arteries or vessels can be visualised with of this significant benefit is furnished by the image
high contrast even if they are superimposed by of the fine-hole lead phantom, which is now dis-
another anatomical structure or organ. Calcifica- played absolutely distortion-free on the TFT
tions, coagulations or lesions become clearly screen (Fig. 16). Combining the significant benefits
visible. Spine, lung and tumour imaging can be of the first fully-digital C-arm described in detail
greatly enhanced. Fig. 13 shows an example of above, i.e. its high detective quantum efficiency,
high dynamics. The same image, acquired with a extra-ordinarily high dynamics and absolutely
conventional image intensifier, shows a major distortion-free image display, with the compre-
oversaturation or overexposure of the circle
located in the centre. Contrast decreases, the
contours become blurred, and so-called “bloom-
ing“ appears (Fig. 14). Greatly improved and arte-
fact-free visualisation possibilities also open up
in vascular surgery and cardiology when using
Digital Subtraction Angiography (DSA) – a method
developed and introduced by Ziehm Imaging in
which contrast-filled vessels are displayed with-
out any interfering background.

Distortion-free imaging – ideal

prerequisites for 3D reconstructions
Fig. 13: Ziehm Vision FD: Illustration of the
Another special feature of digital detectors de- high dynamic range

rives from the fact that image acquisition is ac-

complished without any electron optics. Neither
the earth‘s natural magnetic field nor artificially
generated magnetic fields affect the imaging
chain, giving surgens maximum flexibility when
positioning the C-arm. When a lead phantom with
fine holes is imaged with a conventional image in-
tensifier (Fig. 15), the hole pattern appears with
the typical S-distortion caused by the terrestrial
magnetic field. Not even the algorithm that has
been implemented especially for its compensa-
tion is able to completely eliminate the distortion
of these fine contours. Very strong artificial mag-
netic fields are created e.g. by Magnetic Reso- Fig. 14: The same image acquired with
nance Imaging systems (MRI). The typical site of a conventional image intensifier
07 White Paper No. 03/2010

hensive applications of 3D reconstruction or of

Computer-Aided Surgery (CAS) results in further
considerable benefits for both surgeon and
patient. Ziehm Images uses an FBP (filtered back
projection) algorithm from Feldkamp, Davis &
Kress for 3D reconstruction. The same algorithm
is also used for some larger, stationary CT
systems.

Both technological innovations – the fully-digital

detector and the 3D procedure – are integrated
using inhouse expertise. The evolution of the
scan procedure – from what was originally a strict Fig. 15: Image acquired with a conventional
circular orbit to the full benefits of an elliptical image intensifier
path – pays testimony to the innovative drive of
Ziehm Imaging. The distortion- free imaging char-
acteristics, including insensitivity to magnetic
fields, the resulting fully-digital 3D system is ca-
pable of producing a 3D reconstruction which is
absolutely free from artefacts (Fig. 17). Further-
more, the integrated CAS interface, Ziehm Navi-
Port, enables its adaptation to the navigation sys-
tems of various wellknown software providers. In
navigated, Computer-Aided Surgery, distortion-
free imaging plays a key role. It is the only way to
ensure that surgical instruments can be precisely
positioned. And exact positioning of the surgical
instruments has a direct impact on the outcome of Fig. 16: The distortion-free image acquired
the interventional surgical procedure. When using with the Ziehm Vision FD

a conventional image intensifier, a very time-con-

suming pre-operative image calibration – which enhancing the precision in image generation, it is
serves as a basis for the algorithm used for distor- possible to shorten the duration of the interven-
tion compensation – with the help of a so-called tional procedure, thus cutting down the costs as
‚de-warping‘ grid plate mounted on the image in- well. Furthermore, the surgeon gains more secu-
tensifier is therefore essential (Fig. 18). On some rity, which again contributes to facilitating his/her
systems, the de-warping grid plate is still visible work and to minimising situation-related stress.
on the resulting X-ray image; on others, it This increase in interventional quality directly
is compensated by image interpolation, thus benefits the patient.
making it invisible to the viewer. Neither of the two
methods is very satisfactory for the user, since Summary and outlook
both undoubtedly involve a certain loss of image It was a long way from the first conventional video
information. If the surgeon navigates with the help chain to the nowadays feasible fully-digital imag-
of the distortion-free, fully-digital detector, this ing chain. Many steps of development and sophis-
complicated procedure as well as the de-warping tication were necessary to get there. Access to
grid plate itself are no longer necessary. By global competence resources which were avail-
08 White Paper No. 03/2010

able within the group enabled the company to

choose critically from a variety of innovative de-
tector concepts. The arrival of digital flat-panel
detectors in mobile radiology marks a quantum
leap in the technological development of modern
medical imaging equipment. Targeted research
in the field of photo semiconductor technology
results in enormous benefits both for the patient
and the surgeon. In particular, the combination
of digital detection with the complex applications
of 3D reconstruction or Computer-Aided Surgery
(CAS) opens up new horizons in areas such as
cardiac angiography or neurosurgery. Elevated
Fig. 17: 3D-Reconstruction using
detective quantum efficiency, high dynamics and
flat-panel technology
truly distortionfree imaging clear the way for new
levels of quality and accuracy in image display. An
increase in interventional efficiency and quality
combined with simultaneous cost savings will be
the positive results. Instrumentarium Imaging
Ziehm aspires to assist the users by providing
them with technological support mainly for ad-
vancing their surgical techniques. The scope
ranges from imaging which is individually matched
to certain applications via multi-modality imaging
to userguided, intelligent robotics. Today, the
C-arm forms part of the IT management used in
modern hospitals and will even represent the lo-
cal PACS (Picture Archiving and Communication
System) by adaptation of a workstation specially
designed for that purpose. The C-arm communi-
cates with the existing IT infrastructure via a Fig. 18: Conventional image intensifier with
standard DICOM interface. de-warping grid plate mounted on it
09 White Paper No. 03/2010

Bibliography
[Curry] Christensen’s physics of diagnostic radio-
logy. – 4th ed. / Thomas S. Curry III, James E. Dowdey,
Robert C. Murry, Jr., 1990; 166-169, 175-179

Contact

Peter Berauer, Director Research

peter.berauer@ziehm-eu.com

Günter Stelzer
Director Special Projects and Education
guenter.stelzer@ziehm-eu.com

Ziehm Imaging GmbH

Donaustrasse 31, 90451 Nuremberg
Phone +49.(0) 9 11.21 72-0
Fax +49.(0) 9 11.21 72-390