The AAPM/RSNA physics tutorial for residents: X-ray image intensifiers for fluoroscopy

The x-ray image intensifier converts the transmitted x rays into a brightened, visible light image. Within an image intensifier, the input phosphor converts the x-ray photons to light photons, which are then converted to photoelectrons within the photocathode. The electrons are accelerated and focused by a series of electrodes striking the output phosphor, which converts the accelerated electrons into light photons that may be captured by various imaging devices. Through this process, several thousand light photons are produced for each x-ray photon reaching the input phosphor. Most modern image intensifiers use cesium iodide for the input phosphor because it has a high absorption efficiency and thus decreases patient dose. Image intensifiers come in various sizes, most having more than one input image size or magnification mode. Modern image intensifiers are specified by conversion factors, which is the measure of how efficiently an image intensifier converts x rays to light. Because of design restrictions, image intensifiers are subject to inherent and induced artifacts that contribute to image degradation. Both spatial and contrast resolution gradually decrease during the lifetime of the image intensifier because the brightness gain of an image intensifier decreases with time as the phosphor ages. A well-run quality control program for the image intensifier is needed to detect the inevitable changes in settings before they appear on clinical images.