Medical imaging

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Medical imaging is the technique and

process of creating visual representations
of the interior of a body for clinical
analysis and medical intervention, as well
as visual representation of the function of
some organs or tissues (physiology).
Medical imaging seeks to reveal internal
structures hidden by the skin and bones,
as well as to diagnose and treat disease.
Medical imaging also establishes a
database of normal anatomy and
physiology to make it possible to identify
abnormalities. Although imaging of
removed organs and tissues can be
performed for medical reasons, such
procedures are usually considered part of
pathology instead of medical imaging.
 Medical imaging
Medical diagnostics

A CT scan image showing a ruptured abdominal

aortic aneurysm

ICD-10-PCS B

ICD-9 87 -88

MeSH D003952

OPS-301 3
code

MedlinePlus 007451
As a discipline and in its widest sense, it is
part of biological imaging and
incorporates radiology which uses the
imaging technologies of X-ray radiography,
magnetic resonance imaging, medical
ultrasonography or ultrasound, endoscopy,
elastography, tactile imaging,
thermography, medical photography and
nuclear medicine functional imaging
techniques as positron emission
tomography (PET) and Single-photon
emission computed tomography (SPECT).

Measurement and recording techniques

which are not primarily designed to
produce images, such as
electroencephalography (EEG),
magnetoencephalography (MEG),
electrocardiography (ECG), and others
represent other technologies which
produce data susceptible to
representation as a parameter graph vs.
time or maps which contain data about the
measurement locations. In a limited
comparison these technologies can be
considered as forms of medical imaging in
another discipline.

Up until 2010, 5 billion medical imaging

studies had been conducted worldwide.[1]
Radiation exposure from medical imaging
in 2006 made up about 50% of total
ionizing radiation exposure in the United
States.[2]

Medical imaging is often perceived to

designate the set of techniques that
noninvasively produce images of the
internal aspect of the body. In this
restricted sense, medical imaging can be
seen as the solution of mathematical
inverse problems. This means that cause
(the properties of living tissue) is inferred
from effect (the observed signal). In the
case of medical ultrasonography, the
probe consists of ultrasonic pressure
waves and echoes that go inside the
tissue to show the internal structure. In the
case of projectional radiography, the probe
uses X-ray radiation, which is absorbed at
different rates by different tissue types
such as bone, muscle and fat.

The term noninvasive is used to denote a

procedure where no instrument is
introduced into a patient's body which is
the case for most imaging techniques
used.

Imaging modalities
(a) The results of a CT scan of the head are shown as
successive transverse sections. (b) An MRI machine
generates a magnetic field around a patient. (c) PET
scans use radiopharmaceuticals to create images of

active blood flow and physiologic activity of the organ

or organs being targeted. (d) Ultrasound technology is
used to monitor pregnancies because it is the least
invasive of imaging techniques and uses no
electromagnetic radiation.[3]

In the clinical context, "invisible light"

medical imaging is generally equated to
radiology or "clinical imaging" and the
medical practitioner responsible for
interpreting (and sometimes acquiring) the
images is a radiologist. "Visible light"
medical imaging involves digital video or
still pictures that can be seen without
special equipment. Dermatology and
wound care are two modalities that use
visible light imagery. Diagnostic
radiography designates the technical
aspects of medical imaging and in
particular the acquisition of medical
images. The radiographer or radiologic
technologist is usually responsible for
acquiring medical images of diagnostic
quality, although some radiological
interventions are performed by
radiologists.
As a field of scientific investigation,
medical imaging constitutes a sub-
discipline of biomedical engineering,
medical physics or medicine depending on
the context: Research and development in
the area of instrumentation, image
acquisition (e.g., radiography), modeling
and quantification are usually the preserve
of biomedical engineering, medical
physics, and computer science; Research
into the application and interpretation of
medical images is usually the preserve of
radiology and the medical sub-discipline
relevant to medical condition or area of
medical science (neuroscience, cardiology,
psychiatry, psychology, etc.) under
investigation. Many of the techniques
developed for medical imaging also have
scientific and industrial applications.[3]

Radiography

Two forms of radiographic images are in

use in medical imaging. Projection
radiography and fluoroscopy, with the
latter being useful for catheter guidance.
These 2D techniques are still in wide use
despite the advance of 3D tomography
due to the low cost, high resolution, and
depending on application, lower radiation
dosages. This imaging modality utilizes a
wide beam of x rays for image acquisition
and is the first imaging technique available
in modern medicine.

Fluoroscopy produces real-time images

of internal structures of the body in a
similar fashion to radiography, but
employs a constant input of x-rays, at a
lower dose rate. Contrast media, such
as barium, iodine, and air are used to
visualize internal organs as they work.
Fluoroscopy is also used in image-
guided procedures when constant
feedback during a procedure is required.
An image receptor is required to convert
the radiation into an image after it has
passed through the area of interest.
Early on this was a fluorescing screen,
which gave way to an Image Amplifier
(IA) which was a large vacuum tube that
had the receiving end coated with
cesium iodide, and a mirror at the
opposite end. Eventually the mirror was
replaced with a TV camera.
Projectional radiographs, more
commonly known as x-rays, are often
used to determine the type and extent of
a fracture as well as for detecting
pathological changes in the lungs. With
the use of radio-opaque contrast media,
such as barium, they can also be used
to visualize the structure of the stomach
 and intestines - this can help diagnose
ulcers or certain types of colon cancer.

Magnetic Resonance Imaging

(MRI)

A brain MRI representation

A magnetic resonance imaging instrument

(MRI scanner), or "nuclear magnetic
resonance (NMR) imaging" scanner as it
was originally known, uses powerful
magnets to polarize and excite hydrogen
nuclei (i.e., single protons) of water
molecules in human tissue, producing a
detectable signal which is spatially
encoded, resulting in images of the body.[4]
The MRI machine emits a radio frequency
(RF) pulse at the resonant frequency of the
hydrogen atoms on water molecules.
Radio frequency antennas ("RF coils")
send the pulse to the area of the body to
be examined. The RF pulse is absorbed by
protons, causing their direction with
respect to the primary magnetic field to
change. When the RF pulse is turned off,
the protons "relax" back to alignment with
the primary magnet and emit radio-waves
in the process. This radio-frequency
emission from the hydrogen-atoms on
water is what is detected and
reconstructed into an image. The resonant
frequency of a spinning magnetic dipole
(of which protons are one example) is
called the Larmor frequency and is
determined by the strength of the main
magnetic field and the chemical
environment of the nuclei of interest. MRI
uses three electromagnetic fields: a very
strong (typically 1.5 to 3 teslas) static
magnetic field to polarize the hydrogen
nuclei, called the primary field; gradient
fields that can be modified to vary in space
and time (on the order of 1 kHz) for spatial
encoding, often simply called gradients;
and a spatially homogeneous radio-
frequency (RF) field for manipulation of
the hydrogen nuclei to produce
measurable signals, collected through an
RF antenna.

Like CT, MRI traditionally creates a two

dimensional image of a thin "slice" of the
body and is therefore considered a
tomographic imaging technique. Modern
MRI instruments are capable of producing
images in the form of 3D blocks, which
may be considered a generalization of the
single-slice, tomographic, concept. Unlike
CT, MRI does not involve the use of
ionizing radiation and is therefore not
associated with the same health hazards.
For example, because MRI has only been
in use since the early 1980s, there are no
known long-term effects of exposure to
strong static fields (this is the subject of
some debate; see 'Safety' in MRI) and
therefore there is no limit to the number of
scans to which an individual can be
subjected, in contrast with X-ray and CT.
However, there are well-identified health
risks associated with tissue heating from
exposure to the RF field and the presence
of implanted devices in the body, such as
pace makers. These risks are strictly
controlled as part of the design of the
instrument and the scanning protocols
used.

Because CT and MRI are sensitive to

different tissue properties, the appearance
of the images obtained with the two
techniques differ markedly. In CT, X-rays
must be blocked by some form of dense
tissue to create an image, so the image
quality when looking at soft tissues will be
poor. In MRI, while any nucleus with a net
nuclear spin can be used, the proton of the
hydrogen atom remains the most widely
used, especially in the clinical setting,
because it is so ubiquitous and returns a
large signal. This nucleus, present in water
molecules, allows the excellent soft-tissue
contrast achievable with MRI.

A number of different pulse sequences

can be used for specific MRI diagnostic
imaging (multiparametric MRI or mpMRI).
It is possible to differentiate tissue
characteristics by combining two or more
of the following imaging sequences,
depending on the information being
sought: T1-weighted (T1-MRI), T2-
weighted (T2-MRI), diffusion weighted
imaging (DWI-MRI), dynamic contrast
enhancement (DCE-MRI), and
spectroscopy (MRI-S). For example,
imaging of prostate tumors is better
accomplished using T2-MRI and DWI-MRI
than T2-weighted imaging alone.[5] The
number of applications of mpMRI for
detecting disease in various organs
continues to expand, including liver
studies, breast tumors, pancreatic tumors,
and assessing the effects of vascular
disruption agents on cancer tumors.[6][7][8]

Nuclear medicine

Nuclear medicine encompasses both

diagnostic imaging and treatment of
disease, and may also be referred to as
molecular medicine or molecular imaging
& therapeutics.[9] Nuclear medicine uses
certain properties of isotopes and the
energetic particles emitted from
radioactive material to diagnose or treat
various pathology. Different from the
typical concept of anatomic radiology,
nuclear medicine enables assessment of
physiology. This function-based approach
to medical evaluation has useful
applications in most subspecialties,
notably oncology, neurology, and
cardiology. Gamma cameras and PET
scanners are used in e.g. scintigraphy,
SPECT and PET to detect regions of
biologic activity that may be associated
with disease. Relatively short lived isotope,
such as 99mTc is administered to the
patient. Isotopes are often preferentially
absorbed by biologically active tissue in
the body, and can be used to identify
tumors or fracture points in bone. Images
are acquired after collimated photons are
detected by a crystal that gives off a light
signal, which is in turn amplified and
converted into count data.

Scintigraphy ("scint") is a form of

diagnostic test wherein radioisotopes
are taken internally, for example
intravenously or orally. Then, gamma
cameras capture and form two-
dimensional[10] images from the
radiation emitted by the
radiopharmaceuticals.
SPECT is a 3D tomographic technique
that uses gamma camera data from
many projections and can be
reconstructed in different planes. A dual
detector head gamma camera
combined with a CT scanner, which
provides localization of functional
SPECT data, is termed a SPECT-CT
camera, and has shown utility in
advancing the field of molecular
imaging. In most other medical imaging
modalities, energy is passed through the
body and the reaction or result is read
by detectors. In SPECT imaging, the
patient is injected with a radioisotope,
most commonly Thallium 201TI,
Technetium 99mTC, Iodine 123I, and
Gallium 67Ga.[11] The radioactive
gamma rays are emitted through the
body as the natural decaying process of
these isotopes takes place. The
emissions of the gamma rays are
captured by detectors that surround the
body. This essentially means that the
human is now the source of the
radioactivity, rather than the medical
imaging devices such as X-Ray or CT.
Positron emission tomography (PET)
uses coincidence detection to image
functional processes. Short-lived
positron emitting isotope, such as 18F, is
incorporated with an organic substance
such as glucose, creating F18-
fluorodeoxyglucose, which can be used
as a marker of metabolic utilization.
Images of activity distribution
throughout the body can show rapidly
growing tissue, like tumor, metastasis,
or infection. PET images can be viewed
in comparison to computed tomography
scans to determine an anatomic
correlate. Modern scanners may
integrate PET, allowing PET-CT, or PET-
MRI to optimize the image
reconstruction involved with positron
imaging. This is performed on the same
 equipment without physically moving
the patient off of the gantry. The
resultant hybrid of functional and
anatomic imaging information is a
useful tool in non-invasive diagnosis and
patient management.

Fiduciary markers are used in a wide range

of medical imaging applications. Images
of the same subject produced with two
different imaging systems may be
correlated (called image registration) by
placing a fiduciary marker in the area
imaged by both systems. In this case, a
marker which is visible in the images
produced by both imaging modalities must
be used. By this method, functional
information from SPECT or positron
emission tomography can be related to
anatomical information provided by
magnetic resonance imaging (MRI).[12]
Similarly, fiducial points established during
MRI can be correlated with brain images
generated by magnetoencephalography to
localize the source of brain activity.
Ultrasound representation of Urinary bladder (black
butterfly-like shape) and hyperplastic prostate

Ultrasound

Medical ultrasonography uses high

frequency broadband sound waves in the
megahertz range that are reflected by
tissue to varying degrees to produce (up to
3D) images. This is commonly associated
with imaging the fetus in pregnant women.
Uses of ultrasound are much broader,
however. Other important uses include
imaging the abdominal organs, heart,
breast, muscles, tendons, arteries and
veins. While it may provide less
anatomical detail than techniques such as
CT or MRI, it has several advantages which
make it ideal in numerous situations, in
particular that it studies the function of
moving structures in real-time, emits no
ionizing radiation, and contains speckle
that can be used in elastography.
Ultrasound is also used as a popular
research tool for capturing raw data, that
can be made available through an
ultrasound research interface, for the
purpose of tissue characterization and
implementation of new image processing
techniques. The concepts of ultrasound
differ from other medical imaging
modalities in the fact that it is operated by
the transmission and receipt of sound
waves. The high frequency sound waves
are sent into the tissue and depending on
the composition of the different tissues;
the signal will be attenuated and returned
at separate intervals. A path of reflected
sound waves in a multilayered structure
can be defined by an input acoustic
impedance (ultrasound sound wave) and
the Reflection and transmission
coefficients of the relative structures.[11] It
is very safe to use and does not appear to
cause any adverse effects. It is also
relatively inexpensive and quick to
perform. Ultrasound scanners can be
taken to critically ill patients in intensive
care units, avoiding the danger caused
while moving the patient to the radiology
department. The real time moving image
obtained can be used to guide drainage
and biopsy procedures. Doppler
capabilities on modern scanners allow the
blood flow in arteries and veins to be
assessed.

Elastography
Elastography is a relatively new imaging
modality that maps the elastic properties
of soft tissue. This modality emerged in
the last two decades. Elastography is
useful in medical diagnoses, as elasticity
can discern healthy from unhealthy tissue
for specific organs/growths. For example,
cancerous tumours will often be harder
than the surrounding tissue, and diseased
livers are stiffer than healthy
ones.[13][14][15][16] There are a several
elastographic techniques based on the
use of ultrasound, magnetic resonance
imaging and tactile imaging. The wide
clinical use of ultrasound elastography is a
result of the implementation of technology
in clinical ultrasound machines. Main
branches of ultrasound elastography
include Quasistatic Elastography/Strain
Imaging, Shear Wave Elasticity Imaging
(SWEI), Acoustic Radiation Force Impulse
imaging (ARFI), Supersonic Shear Imaging
(SSI), and Transient Elastography.[14] In the
last decade a steady increase of activities
in the field of elastography is observed
demonstrating successful application of
the technology in various areas of medical
diagnostics and treatment monitoring.
3D tactile image (C) is composed from 2D pressure
maps (B) recorded in the process of tissue phantom
examination (A).

Tactile imaging

Tactile imaging is a medical imaging

modality that translates the sense of touch
into a digital image. The tactile image is a
function of P(x,y,z), where P is the pressure
on soft tissue surface under applied
deformation and x,y,z are coordinates
where pressure P was measured. Tactile
imaging closely mimics manual palpation,
since the probe of the device with a
pressure sensor array mounted on its face
acts similar to human fingers during
clinical examination, slightly deforming
soft tissue by the probe and detecting
resulting changes in the pressure pattern.
Figure on the right presents an experiment
on a composite tissue phantom examined
by a tactile imaging probe illustrating the
ability of tactile imaging to visualize in 3D
the structure of the object.
This modality is used for imaging of the
prostate,[17] breast,[18] vagina and pelvic
floor support structures ,[19] and
myofascial trigger points in muscle.[20]

Photoacoustic imaging

Photoacoustic imaging is a recently

developed hybrid biomedical imaging
modality based on the photoacoustic
effect. It combines the advantages of
optical absorption contrast with ultrasonic
spatial resolution for deep imaging in
(optical) diffusive or quasi-diffusive
regime. Recent studies have shown that
photoacoustic imaging can be used in vivo
for tumor angiogenesis monitoring, blood
oxygenation mapping, functional brain
imaging, and skin melanoma detection,
etc.

Tomography

Fig.1: Basic principle of tomography: superposition

free tomographic cross sections S1 and S2 compared
with the (not tomographic) projected image P
Tomography is the imaging by sections or
sectioning. The main such methods in
medical imaging are:

X-ray computed tomography (CT), or

Computed Axial Tomography (CAT)
scan, is a helical tomography technique
(latest generation), which traditionally
produces a 2D image of the structures
in a thin section of the body. In CT, a
beam of X-rays spins around an object
being examined and is picked up by
sensitive radiation detectors after
having penetrated the object from
multiple angles. A computer then
analyses the information received from
the scanner's detectors and constructs
a detailed image of the object and its
contents using the mathematical
principles laid out in the Radon
transform. It has a greater ionizing
radiation dose burden than projection
radiography; repeated scans must be
limited to avoid health effects. CT is
based on the same principles as X-Ray
projections but in this case, the patient
is enclosed in a surrounding ring of
detectors assigned with 500-1000
scintillation detectors[11] (fourth-
generation X-Ray CT scanner geometry).
Previously in older generation scanners,
the X-Ray beam was paired by a
 translating source and detector.
Computed tomography has almost
completely replaced focal plane
tomography in X-ray tomography
imaging.
Positron emission tomography (PET)
also used in conjunction with computed
tomography, PET-CT, and magnetic
resonance imaging PET-MRI.
Magnetic resonance imaging (MRI)
commonly produces tomographic
images of cross-sections of the body.
(See separate MRI section in this
article.)

Echocardiography
When ultrasound is used to image the
heart it is referred to as an
echocardiogram. Echocardiography allows
detailed structures of the heart, including
chamber size, heart function, the valves of
the heart, as well as the pericardium (the
sac around the heart) to be seen.
Echocardiography uses 2D, 3D, and
Doppler imaging to create pictures of the
heart and visualize the blood flowing
through each of the four heart valves.
Echocardiography is widely used in an
array of patients ranging from those
experiencing symptoms, such as
shortness of breath or chest pain, to those
undergoing cancer treatments.
Transthoracic ultrasound has been proven
to be safe for patients of all ages, from
infants to the elderly, without risk of
harmful side effects or radiation,
differentiating it from other imaging
modalities. Echocardiography is one of the
most commonly used imaging modalities
in the world due to its portability and use
in a variety of applications. In emergency
situations, echocardiography is quick,
easily accessible, and able to be
performed at the bedside, making it the
modality of choice for many physicians.

Functional near-infrared
spectroscopy
FNIR Is a relatively new non-invasive
imaging technique. NIRS (near infrared
spectroscopy) is used for the purpose of
functional neuroimaging and has been
widely accepted as a brain imaging
technique.[21]

Magnetic Particle Imaging

Using superparamagnetic iron oxide

nanoparticles, magnetic particle imaging
(MPI) is a developing diagnostic imaging
technique used for tracking
superparamagnetic iron oxide
nanoparticles. The primary advantage is
the high sensitivity and specificity, along
with the lack of signal decrease with
tissue depth. MPI has been used in
medical research to image cardiovascular
performance, neuroperfusion, and cell
tracking.

In pregnancy

CT scanning (volume rendered in this case) confers a

radiation dose to the developing fetus.
Medical imaging may be indicated in
pregnancy because of pregnancy
complications, intercurrent diseases or
routine prenatal care. Magnetic resonance
imaging (MRI) without MRI contrast
agents as well as obstetric
ultrasonography are not associated with
any risk for the mother or the fetus, and
are the imaging techniques of choice for
pregnant women.[22] Projectional
radiography, X-ray computed tomography
and nuclear medicine imaging result some
degree of ionizing radiation exposure, but
have with a few exceptions much lower
absorbed doses than what are associated
with fetal harm.[22] At higher dosages,
effects can include miscarriage, birth
defects and intellectual disability.[22]

Maximizing imaging
procedure use
The amount of data obtained in a single
MR or CT scan is very extensive. Some of
the data that radiologists discard could
save patients time and money, while
reducing their exposure to radiation and
risk of complications from invasive
procedures.[23] Another approach for
making the procedures more efficient is
based on utilizing additional constraints,
e.g., in some medical imaging modalities
one can improve the efficiency of the data
acquisition by taking into account the fact
the reconstructed density is positive.[24]

Creation of three-
dimensional images
Volume rendering techniques have been
developed to enable CT, MRI and
ultrasound scanning software to produce
3D images for the physician.[25]
Traditionally CT and MRI scans produced
2D static output on film. To produce 3D
images, many scans are made, then
combined by computers to produce a 3D
model, which can then be manipulated by
the physician. 3D ultrasounds are
produced using a somewhat similar
technique. In diagnosing disease of the
viscera of abdomen, ultrasound is
particularly sensitive on imaging of biliary
tract, urinary tract and female reproductive
organs (ovary, fallopian tubes). As for
example, diagnosis of gall stone by
dilatation of common bile duct and stone
in common bile duct. With the ability to
visualize important structures in great
detail, 3D visualization methods are a
valuable resource for the diagnosis and
surgical treatment of many pathologies. It
was a key resource for the famous, but
ultimately unsuccessful attempt by
Singaporean surgeons to separate Iranian
twins Ladan and Laleh Bijani in 2003. The
3D equipment was used previously for
similar operations with great success.

Other proposed or developed techniques

include:

Diffuse optical tomography

Elastography
Electrical impedance tomography
Optoacoustic imaging
Ophthalmology
A-scan
B-scan
 Corneal topography
Optical coherence tomography
Scanning laser ophthalmoscopy

Some of these techniques are still at a

research stage and not yet used in clinical
routines.

Non-diagnostic imaging
Neuroimaging has also been used in
experimental circumstances to allow
people (especially disabled persons) to
control outside devices, acting as a brain
computer interface.
Many medical imaging software
applications (3DSlicer, ImageJ, MIPAV,
ImageVis3D, etc.) are used for non-
diagnostic imaging, specifically because
they don't have an FDA approval[26] and not
allowed to use in clinical research for
patient diagnosis.[27] Note that many
clinical research studies are not designed
for patient diagnosis anyway.[28]

Archiving and recording

Used primarily in ultrasound imaging,
capturing the image produced by a
medical imaging device is required for
archiving and telemedicine applications. In
most scenarios, a frame grabber is used in
order to capture the video signal from the
medical device and relay it to a computer
for further processing and operations.[29]

DICOM

The Digital Imaging and Communication in

Medicine (DICOM) Standard is used
globally to store, exchange, and transmit
medical images. The DICOM Standard
incorporates protocols for imaging
techniques such as radiography, computed
tomography (CT), magnetic resonance
imaging (MRI), ultrasonography, and
radiation therapy.[30] DICOM includes
standards for image exchange (e.g., via
portable media such as DVDs), image
compression, 3-D visualization, image
presentation, and results reporting.[31]

Compression of medical
images

Medical imaging techniques produce very

large amounts of data, especially from CT,
MRI and PET modalities. As a result,
storage and communications of electronic
image data are prohibitive without the use
of compression. JPEG 2000 is the state-
of-the-art image compression DICOM
standard for storage and transmission of
medical images. The cost and feasibility
of accessing large image data sets over
low or various bandwidths are further
addressed by use of another DICOM
standard, called JPIP, to enable efficient
streaming of the JPEG 2000 compressed
image data.

Medical Imaging in the Cloud

There has been growing trend to migrate

from PACS to a Cloud Based RIS. A recent
article by Applied Radiology said, "As the
digital-imaging realm is embraced across
the healthcare enterprise, the swift
transition from terabytes to petabytes of
data has put radiology on the brink of
information overload. Cloud computing
offers the imaging department of the
future the tools to manage data much
more intelligently."[32]

Use in pharmaceutical
clinical trials
Medical imaging has become a major tool
in clinical trials since it enables rapid
diagnosis with visualization and
quantitative assessment.

A typical clinical trial goes through

multiple phases and can take up to eight
years. Clinical endpoints or outcomes are
used to determine whether the therapy is
safe and effective. Once a patient reaches
the endpoint, he or she is generally
excluded from further experimental
interaction. Trials that rely solely on
clinical endpoints are very costly as they
have long durations and tend to need large
numbers of patients.

In contrast to clinical endpoints, surrogate

endpoints have been shown to cut down
the time required to confirm whether a
drug has clinical benefits. Imaging
biomarkers (a characteristic that is
objectively measured by an imaging
technique, which is used as an indicator of
pharmacological response to a therapy)
and surrogate endpoints have shown to
facilitate the use of small group sizes,
obtaining quick results with good
statistical power.[33]

Imaging is able to reveal subtle change

that is indicative of the progression of
therapy that may be missed out by more
subjective, traditional approaches.
Statistical bias is reduced as the findings
are evaluated without any direct patient
contact.

Imaging techniques such as positron

emission tomography (PET) and magnetic
resonance imaging (MRI) are routinely
used in oncology and neuroscience
areas,.[34][35][36][37] For example,
measurement of tumour shrinkage is a
commonly used surrogate endpoint in
solid tumour response evaluation. This
allows for faster and more objective
assessment of the effects of anticancer
drugs. In Alzheimer's disease, MRI scans
of the entire brain can accurately assess
the rate of hippocampal atrophy, while PET
scans can measure the brain's metabolic
activity by measuring regional glucose
metabolism,[33] and beta-amyloid plaques
using tracers such as Pittsburgh
compound B (PiB). Historically less use
has been made of quantitative medical
imaging in other areas of drug
development although interest is
growing.[38]

An imaging-based trial will usually be

made up of three components:

1. A realistic imaging protocol. The

protocol is an outline that standardizes (as
far as practically possible) the way in
which the images are acquired using the
various modalities (PET, SPECT, CT, MRI).
It covers the specifics in which images are
to be stored, processed and evaluated.
2. An imaging centre that is responsible
for collecting the images, perform quality
control and provide tools for data storage,
distribution and analysis. It is important
for images acquired at different time
points are displayed in a standardised
format to maintain the reliability of the
evaluation. Certain specialised imaging
contract research organizations provide
end to end medical imaging services, from
protocol design and site management
through to data quality assurance and
image analysis.
3. Clinical sites that recruit patients to
generate the images to send back to the
imaging centre.
Shielding
Lead is the main material used for
radiographic shielding against scattered X-
rays.

In magnetic resonance imaging, there is

MRI RF shielding as well as magnetic
shielding to prevent external disturbance
of image quality.

Privacy protection
Medical imaging are generally covered by
laws of medical privacy. For example, in
the United States the Health Insurance
Portability and Accountability Act (HIPAA)
sets restrictions for health care providers
on utilizing protected health information,
which is any individually identifiable
information relating to the past, present, or
future physical or mental health of any
individual.[39] While there has not been any
definitive legal decision in the matter, at
least one study has indicated that medical
imaging may contain biometric
information that can uniquely identify a
person, and so may qualify as PHI.[40]

The UK General Medical Council's ethical

guidelines indicate that the Council does
not require consent prior to secondary
uses of X-ray images.[41]
Copyright
United States

As per Compendium: Chapter 300 by the

US Copyright Office , "the Office will not
register works produced by a machine or
mere mechanical process that operates
randomly or automatically without any
creative input or intervention from a
human author." including "Medical imaging
produced by x-rays, ultrasounds, magnetic
resonance imaging, or other diagnostic
equipment." This position differs from the
broad copyright protections afforded to
photographs. While the Copyright
Compendium is an agency statutory
interpretation and not legally binding,
courts are likely to give deference to it if
they find it reasonable.[42] Yet, there is no
U.S. federal case law directly addressing
the issue of the copyrightability of x-ray
images.

Derivatives

In a derivative of a medical image created in the U.S.,

added annotations and explanations may be
copyrightable, but the medical image itself remains
Public Domain.

An extensive definition of the term

derivative work is given by the United
States Copyright Act in 17 U.S.C. § 101 :

A “derivative work” is a work

based upon one or more
preexisting works, such as a
translation...[note 1] art
reproduction, abridgment,
condensation, or any other form
in which a work may be recast,
 transformed, or adapted. A work
consisting of editorial revisions,
annotations, elaborations, or
other modifications which, as a
whole, represent an original work
of authorship, is a “derivative
work”.

17 U.S.C. § 103(b) provides:

The copyright in a compilation or

derivative work extends only to
the material contributed by the
 author of such work, as
distinguished from the
preexisting material employed in
the work, and does not imply any
exclusive right in the preexisting
material. The copyright in such
work is independent of, and does
not affect or enlarge the scope,
duration, ownership, or
subsistence of, any copyright
protection in the preexisting
material.

Germany
In Germany, X-ray images as well as MRT,
ultrasound, PET and scintigraphy images
are protected by (copyright-like) related
rights or neighbouring rights.[43] This
protection does not require creativity (as
would be necessary for regular copyright
protection) and lasts only for 50 years
after image creation, if not published
within 50 years, or for 50 years after the
first legitimate publication.[44] The letter of
the law grants this right to the
"Lichtbildner"[9] , i.e. the person who
created the image. The literature seems to
uniformly consider the medical doctor,
dentist or veterinary physician as the
rights holder, which may result from the
circumstance that in Germany many x-rays
are performed in ambulatory setting and
that the doctor prescribes the settings for
the individual imaging.

United Kingdom

Medical images created in the United

Kingdom will normally be protected by
copyright due to "the high level of skill,
labour and judgement required to produce
a good quality x-ray, particularly to show
contrast between bones and various soft
tissues".[45] The Society of Radiographers
believe this copyright is owned by
employer (unless the radiographer is self-
employed -- though even then their
contract might require them to transfer
ownership to the hospital). This copyright
owner can grant certain permissions to
whoever they wish, without giving up their
ownership of the copyright. So the hospital
and its employees will be given permission
to use such radiographic images for the
various purposes that they require for
medical care. Physicians employed at the
hospital will, in their contracts, be given
the right to publish patient information in
journal papers or books they write
(providing they are made anonymous).
Patients may also be granted permission
to "do what they like with" their own
images.

Sweden

The Cyber Law in Sweden (pg. 96) states:

"Pictures can be protected as
photographic works or as photographic
pictures. The former requires a higher level
of originality; the latter protects all types of
photographs, also the ones taken by
amateurs, or within medicine or science.
The protection requires some sort of
photographic technique being used, which
includes digital cameras as well as
holograms created by laser technique. The
difference between the two types of work
is the term of protection, which amounts
to seventy years after the death of the
author of a photographic work as opposed
to fifty years, from the year in which the
photographic picture was taken."

Medical imaging may possibly be included

in the scope of "photography", similarly to
a U.S. statement that "MRI images, CT
scans, and the like are analogous to
photography."[46]

Notes
1. musical arrangement, dramatization,
fictionalization, motion picture version,
sound recording

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43. Per §72 UrhG [2] like “simple images”
(Lichtbild)
44.
Scholarly legal literature:(Schulze, in:
Dreier/Schulze, 2013, §72 Rdnr. 6 w.
reference to Schricker/Vogel §72 Rdnr.
18 and Wandtke/Bullinger/Thum §72
Rdnr. 10 [3] and Thum, in:
Wandtke/Bullinger, UrhG, 32009, §72,
Rn. 15.)
Legal commentaries: K. Hartung, E.
Ludewig, B. Tellhelm:
Röntgenuntersuchung in der
Tierarztpraxis. Enke, 2010[4] or T.
Hillegeist: Rechtliche Probleme der
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wissenschaftlicher Primärdaten.
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Indirectly by a ruling of a German 2nd-
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Oktober 1985, Az. 7 S 90/85[7] ), which
mentions copyright in x-ray images,
and by the Röntgenverordnung of
Germany, a federal regulation about the
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46. "Laser Bones: Copyright Issues Raised
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Further reading
A good comprehensive Medical Imaging
Textbook albeit a bit dated: Cho, Zang-
Hee, Joie P. Jones, and Manbir Singh.
Foundations of medical imaging. New
York:: Wiley, 1993. ISBN 0-471-54573-2
 Eisenberg, Ronald L.; Margulis,
Alexander R.: A Patient's Guide to
Medical Imaging. Oxford University
Press, 2011. ISBN 978-0-19-972991-3
Jayaram K. Udupa, Gabor T. Herman “3D
Imaging in Medicine, Second Edition” 2
September 28, 1999 by CRC Press

External links
Wikimedia Commons has media related
to Medical imaging.

Medical imaging at Curlie (based on

DMOZ)
IPRG Open group related to image
processing research resources
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title=Medical_imaging&oldid=817486089"

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