Don et al.

Pe d i a t r i c I m a g i n g • C l i n i c a l O b s e r v a t i o n s
Neonatal Computed
Radiography
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Neonatal Chest Computed

Radiography: Image Processing
and Optimal Image Display
Steven Don1,2 OBJECTIVE. The purpose of this study was to determine soft-copy image display prefer-
Bruce R. Whiting2 ences of brightness, latitude, and detail contrast for neonatal chest computed radiography to es-
Jacquelyn S. Ellinwood3 tablish a baseline for future work on low-dose imaging.
David H. Foos3 CONCLUSION. Observers preferred brighter images with higher detail contrast and nar-
Keith A. Kronemer1 row to middle latitude for soft-copy display compared with the typical screen-film hard-copy
appearance. Future research on low-dose neonatal chest imaging will be facilitated by an un-
Richard A. Kraus1
derstanding of optimal soft-copy image display.
Don S, Whiting BR, Ellinwood JS, Foos DH,
Kronemer KA, Kraus RA raditional screen-film radiographs ment and signal equalization, also may be used

T have a characteristic density/log

Keywords: chest, digital images, neonatal imaging, PACS,
pediatric radiology
DOI:10.2214/AJR.05.0733
Received April 29, 2005; accepted after revision
November 10, 2005.
Presented at the 2004 annual meeting of the American
Roentgen Ray Society, Miami Beach, FL.
Supported in part by National Institutes of Health research
grant 1 R41 HD40747-01.
The employment status of J. S. Ellinwood and D. H. Foos at
Eastman Kodak Company did not influence the data in this
study.
1Mallinckrodt
Institute for Radiology, St. Louis Children’s
Hospital, Washington University School of Medicine,
510 S Kingshighway, St. Louis, MO, 63110. Address
correspondence to S. Don (dons@mir.wustl.edu).
2Electronic Research Laboratory, Mallinckrodt Institute for
Radiology, Washington University School of Medicine,
St. Louis, MO.
3Eastman Kodak Company, Rochester, NY.
AJR 2007; 188:1138–1144
0361–803X/07/1884–1138
© American Roentgen Ray Society
(exposure) response (Hurter and
Driffield curve or tone scale) that is
sigmoidal in shape and determines the density
and contrast of screen-film images at a specific
peak kilovoltage and effective tube current [1].
An underexposed image falls in the toe of the
characteristic curve, and an overexposed image
falls in the shoulder of the characteristic curve.
The signal response in computed radiogra-
phy (CR) is linear with exposure, resulting in
a wider dynamic range: 100- to 1,000-fold
greater than that of screen-film radiography.
The result is better tolerance of underexposure
and overexposure with CR, but the unproc-
essed raw image data do not have the proper
image contrast and density necessary for im-
age interpretation [2, 3]. Image processing of
raw CR digital data frequently results in the
screen-film radiographic appearance that radi-
ologists are accustomed to interpreting. This
appearance typically is achieved because of la-
ser printing of the image on film. Hospitals,
however, have begun to convert to soft-copy
image display.
Image processing, because of the unproc-
essed raw image data, must include recognition
of the amount of exposure the X-ray plate re-
ceives in the relevant anatomic regions. Gray-
scale rendition is then applied to achieve appro-
priate overall brightness in the displayed image.
Gray-scale rendition is performed to simulate
the Hurter and Driffield curve and to produce
an image acceptable to radiologists. Special-
ized image processing, such as edge enhance-
to emphasize features in the CR images [2, 3].
Because of concerns about patient radiation
dose, it is desirable to perform CR examina-
tions with a dose level as low as reasonably
achievable while maintaining an acceptable
level of image noise [4]. These requirements
can be met by changing radiographic parame-
ters, such as peak kilovoltage and effective
tube current, or by using image processing to
suppress noise while preserving image fea-
tures. Many neonatal dose-reduction studies
have been performed with laser-printed film
and fixed image processing [5–7]. In those
studies, investigators tested the effects of dose
reduction on the diagnosis of hyaline mem-
brane disease and pneumothorax [5–7].
Soft-copy image display parameters must
be controlled to prevent interacting effects
from confounding dose-reduction experi-
ments. Soft-copy image display preferences
for adult chest CR were determined in a previ-
ous study [8], but requirements for soft-copy
image display preferences for neonatal chest
CR are unknown. Because of concerns about
radiation sensitivity in children, research is be-
ing conducted into methods of reducing radia-
tion dose in CR. The purposes of this research
are to determine user preferences for neonatal
chest CR soft-copy image display as a baseline
for future soft-copy work on low-dose imaging
and to gain an understanding of which factors
are important in the optimal presentation of
neonatal images. The effects of low-dose expo-
sure on observer performance in the detection
of disease can then be studied.

1138 AJR:188, April 2007

 Neonatal Computed Radiography
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A B

4,500
4,000
Lung
3,500 Lowest brightness
Output Code Value

3,000
2,500 Middle brightness
2,000
1,500 Highest brightness
1,000
Bone
500
0
1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000
Input Code Value

C D
Fig. 1—Normal neonatal chest radiographs illustrate response curve to brightness adjustments for neonatal chest computed radiography. Lungs appear progressively lighter
from lowest brightness to highest brightness.
A, Low-brightness image.
B, Reference T-MAT G (Eastman Kodak Company) image.
C, High-brightness image.
D, Graph shows adjustment of characteristic curve from lowest to highest brightness. At fixed input code value, lowest brightness images have higher or more lung density
output and highest brightness images have lower or more bone density output.

Materials and Methods
Image Acquisition
This study received the approval of our institu-
tional review board. All image data were handled
according to the Health Insurance Portability and
Accountability Act (HIPAA). Images were ob-
tained with a Kodak 400 CR system (Eastman
Kodak Company). Five chest radiographs of
healthy neonates and five chest radiographs of ne-
onates with clearly discernible pneumothorax were
selected. Raw image data were collected at a qual-
ity-control workstation with all image processing
turned off. These data were transferred to another
workstation for removal of all patient identification
data and then were sent to an analysis workstation.
Imaging Processing
The raw image data were processed with a proto-
type image-processing algorithm [8]. Three variables
were altered: brightness, detail contrast, and latitude. A
control image for each patient was acquired to simulate
the characteristic response curve of T-MAT G film
(Eastman Kodak Company). This screen-film combi-
nation is common in pediatric chest radiography.
Brightness is increased on a CR image through
a shift in the response curve to the right (Fig. 1).
This control is analogous to the level in CT image
display in which the lungs are dark at a mediastinal
level and bright at a lung level.
Detail contrast is increased on a CR image
through an increase in the slope of the linear portion
of the response curve. Low-detail contrast images
appear grayer, and high-detail contrast images are
more black and white (Fig. 2). This control is anal-
ogous to the window in CT in which shallow lung
window contrast minimizes the contrast difference
between water and soft tissue and steep mediasti-
num window contrast accentuates the difference
between water and soft tissue.
Latitude adjustment on a CR image changes the
overall contrast of an image without affecting local
contrast or resolution. For a wide-latitude image, one
compresses the large-area, low-frequency data of the
histogram information and subtracts that from the
histogram of the image. The overall appearance of
the image is grayer yet retains local contrast. For ex-

AJR:188, April 2007 1139

 Don et al.
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A B
Fig. 2—Normal neonatal chest radiographs show detail contrast adjustment of response
4,500
curve for neonatal chest computed radiograph. See reference image in Figure 1B for
4,000 comparison. Difference in contrast between air in stomach and ribs is evident.
Lung
Lowest contrast = 2.5
3,500 A, Low-detail contrast image appears gray.
Output Code Value

T-MAT G contrast = 3.1

3,000 B, High-detail contrast image is more black and white than A.
2,500 C, Graph shows adjustment of response curve. As detail contrast increases,
2,000
characteristic curve becomes steeper (T-MAT G, Eastman Kodak Company).
1,500
1,000
Bone Highest contrast = 4.0
500
0
1,500 1,700 1,900 2,100 2,300 2,500 2,700 2,900
Input Code Value

4,500
4,000
Lung
3,500
Output Code Value

Latitude = 0.56
3,000
2,500
2,000
1,500
1,000 Latitude = 1.46
Bone 500
0
0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000
Input Code Value

A B
Fig. 3—Normal neonatal chest radiograph with latitude adjustment of response curve for neonatal chest computed radiograph. See reference image in Figure 1B for
comparison. Difference in free-in-air exposure and soft tissue around humerus is evident.
A, Wide-latitude image appears gray.
B, Graph shows adjustment of characteristic curve. As latitude increases, steepness of response curve decreases. This finding applies to low-spatial-frequency data only.

ample, the contrast between a rib and adjacent lung tures such as lung markings and bone detail and min- contrast, and latitude for a neonate with pneumotho-
is maintained, but the contrast between the free-in- imizes differences such as density difference be- rax are presented in Figure 4.
air exposure and soft tissues around the humerus is tween lungs. Examples of the effect of altering the Each case was processed with five brightness
decreased (Fig. 3). This manipulation highlights fea- image-processing parameters of brightness, detail levels, four detail contrast levels, and seven latitude

1140 AJR:188, April 2007

 Neonatal Computed Radiography
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A B C

D E F
Fig. 4—Neonatal chest radiographs with pneumothorax. Images show effects of brightness, detail contrast, and latitude adjustment on neonatal chest radiographs.
A, Reference image.
B, Low-brightness image.
C, High-brightness image.
D, Low-contrast image.
E, High-contrast image.
F, Wide-latitude image.

levels. One hundred ten combinations of 140 possi-
ble combinations of each patient’s image were
made. The processing parameter matrix was not
symmetric, and the narrower-latitude and lower-
detail contrast images were not acquired because
observation [8] had shown the range of lowest lati-
tude and contrast performed the worst. With this
criterion, 30 image combinations per patient were
eliminated without alteration of the results, allow-
ing reduction of computational time and enhance-
ment of observer participation.
Combinations were achieved by adjustment of
the tone scale with a fixed shape that approximately
matched the tone scale curve of T-MAT G film. The
middle brightness level was chosen as the level that
would yield an optical density of approximately 1.65
on a T-MAT G film image of the lung region. Bright-
ness adjustments were achieved by shifting the tone
scale along the input axis in increments of 75 and
150 code values above and below the middle bright-
ness code value for each image to yield lowest,
lower, middle, high, and highest brightness settings.
At the reference detail contrast setting, that adjust-
ment would yield optical densities in the lung region
of, from low to high, 2.25, 1.95, 1.65, 1.35, and 1.15.
Detail contrast adjustments were achieved by pivot-
ing the tone scale at set increments around the input
value corresponding to a density of 1.0. Latitude ad-
justments were achieved by reducing the low-fre-
quency contrast at set increments while maintaining
the detail contrast, achieved through a signal-equal-
ization filtering step.
The control image-processing parameters were
chosen as the image at middle brightness (one that
would yield an optical density of approximately
1.65 on T-MAT G film in the lung region), low-de-
tail contrast (T-MAT G film contrast of 3.1), and
narrow latitude (one that would maintain the tonal
characteristics of low-frequency data for a detail
contrast level of 3.1). These parameters would sim-
ulate on soft-copy display the hard-copy screen-
film appearance of neonatal chest radiographs.

AJR:188, April 2007 1141


Image Viewing
One hundred ten images were acquired for each
of 10 sets of neonatal CR images for a total of 1,100
images. These images were randomized and pre-
sented in 10 sessions of 110 images. The images
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were viewed with a stand-alone PC workstation on
a high-resolution (2,000 × 2,500) cathode ray tube
monitor (model DR 110, Data Ray). The monitor
was calibrated, and lighting was controlled to elim-
inate glare on the screen. The workstation was in a
quiet room for elimination of extraneous noise.
Each test image was presented along with the
control processed image. The observer toggled be-
tween the test image and the control image and con-
trolled the toggle rate and amount of observation
time before rating. Three pediatric radiologists with
certificates of added qualification in pediatric radi-
ology participated in the image review. These radi-
ologists were familiar with soft-copy interpretation.
Each radiologist rated each image on a nine-point
viewing scale relative to the control image as in pre-
viously published adult work [8]: 4, image quality
markedly better, diagnosis likely altered; 3, image
quality clearly better, diagnosis might be altered; 2,
image quality somewhat better, diagnosis should be
the same; 1, image quality slightly better, diagnosis
will be the same; 0, no difference; –1, image quality
slightly worse, diagnosis will be the same; –2, im-
age quality somewhat worse, diagnosis should be
the same; –3, image quality clearly worse, diagno-
sis might be altered; –4, image quality markedly
worse, diagnosis likely altered.
Statistical Analysis
A regression model with a second-order polyno-
mial was used to analyze the data. The factors of
brightness, latitude, and detail contrast were treated
as continuous. A logarithmic transform of the lati-
tude was used to improve conformance to the poly-
nomial fit. Brightness, detail contrast, and log-lati-
tude levels were centered to reduce the correlation
between predictor values, thus clarifying signifi-
cance testing. In addition, health condition (pres-
ence or absence of pneumothorax) was included as
a discrete and fixed effect. Observer and patient ef-
fects were treated as discrete and random, and the
patient effect was considered nested within the
health condition.
The peak soft-copy viewing preference range of
detail contrast and latitude cell at each brightness
level was determined. The best-rated cell at each
brightness level was identified. The 95% CI was de-
termined for the difference between the predicted
mean of the cell with the best rating and the pre-
dicted mean of the cell being checked. All cells
identified as not significantly different from the
best rating cell were included in the peak prefer-
ence range for each brightness level.
1142
Don et al.
Results
The regression results showed that bright-
ness (p < 0.01) was the single most impor-
tant factor in determining user imaging and
diagnostic preferences (Table 1). Also sig-
nificant in order of contribution to the vari-
ance were observer, detail contrast, latitude,
and patient (Table 1). The presence or ab-
sence of pneumothorax was not statistically
significant (p = 0.14).
There was a peak cell-rating difference of
three points between the user-preference pre-
dicted best cell rating at the lowest brightness
(–1.7) and the user-preference predicted best
cell rating at the highest brightness (1.3). At
the lowest brightness, all scores were signifi-
cantly less than 0, indicating that the images
at this brightness level, regardless of detail
contrast and latitude, were less desirable than
the reference image in image and diagnostic
quality (Table 2). At the middle brightness
level, which included the reference image, the
predicted ratings were near 0 (Table 3). The
ratings at the highest brightness and highest
detail contrast and narrow latitude had the
highest predicted score (Table 4). At none of
the image brightness settings was there a sta-
tistically significant difference between the
ratings for healthy patients and those for pa-
tients with pneumothorax.
Discussion
Despite the presence of CR in pediatric im-
aging for nearly 20 years [9], to our knowl-
edge no scientific methodology has been de-
veloped for addressing specific soft-copy
viewing preferences. Years ago, a hard-copy
CR film included two images, one imitating a
screen-film radiograph and a second that en-
hanced edge structures, such as catheters [8,
9]. Currently, one hard-copy CR film melds
the screen-film appearance and edge en-
hancement. Our findings clearly indicate that
soft-copy viewing preferences in neonatal
chest CR are different from the established
hard-copy screen-film radiographic prefer-
ences [8]. Our findings establish baseline
soft-copy settings for future use in image dis-
play and dose-reduction research.
More radiology departments are shifting to
soft-copy display and eliminating film entirely.
Much work has been done to meet the chal-
lenge of PACS and soft-copy display [10]. Re-
search has focused on comparing soft-copy
display with hard-copy film [11], resolution of
the monitor [11], CR with other digital radio-
graphic systems [12, 13], and monitor lumi-
nance [14–16]. In these studies, the images
were initially displayed from fixed, preset im-
age-processing algorithms. In our study, the
image-processing parameters were the tested
variables. In three of the previous studies
[12–14], it was explicitly stated that radiolo-
gists were allowed to adjust window and level
but not spatial filtering. In one study [14], the
radiologists manipulated window and level
settings 90% of the time. In only one study [8],
with adult subjects, were preferred soft-copy
display settings evaluated.
Our study of neonatal chest CR images
showed that pediatric radiologists find im-
proved image and diagnostic quality of soft-
copy display with the brightest image setting
and with high-detail contrast and narrow to
middle latitude processing settings. Adjusting
the CR image display resulted in a higher rat-
ing by the radiologists compared with the ref-
erence screen-film radiographic appearance.
The CR viewing preference was different from
the screen-film radiographic appearance of the
characteristic response curve of T-MAT G
film, which is middle brightness, narrow lati-
tude, and less detail contrast. Wide-latitude im-
ages were not preferred for routine viewing.
The parameters that were varied in this ex-
periment (brightness, detail contrast, and lat-
itude) are the building blocks of image qual-
ity. As such, the results can be generalized for
use with most CR systems, provided the inter-
face with image processing has the required
flexibility. Although the particular image pro-
cessing (rendering) parameters are different
among CR systems, the functionality of im-
age processing can be related to these three
fundamentals of image quality.
The results of this study can be applied to
soft-copy and hard-copy interpretation, pro-
vided the image-processing parameters are
adapted to compensate image appearance for
the dynamic range, gray-scale resolution, and
spatial resolution differences among printers
and soft displays. The concept of the building
blocks of image quality has been detailed [17].
In a previous study [8] of posteroanterior
chest radiographs of adults, the radiologists
preferred a wide-latitude (highly equalized)
image with less detail contrast, different from
the user preferences we found. One explana-
tion may be that adult chest images have a
broader histogram range than chest images of
neonates. This difference is attributable to the
size difference between neonates and adults.
The anatomic structures of neonates are less
attenuating than are those of adults. The typi-
cal peak kilovoltage used for neonatal chest
radiographs is 60–70 kVp, whereas that for
AJR:188, April 2007
 Neonatal Computed Radiography

TABLE 1: Regression Model Results This finding implies that there is no need for
Source of Variation Degrees of Freedom F p routine alteration of image display for routine
Brightness 1 2,734.44 < 0.01a evaluation for pneumothorax. This study, how-
ever, did not test ability to diagnose subtle cases
Observer 2 235.68 < 0.01a
of pneumothorax. A previous study of neonatal
Detail contrast 1 99.12 < 0.01a
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chest images showed that edge enhancement,

Latitude 1 19.85 < 0.01a which was not investigated in this study, im-
Patient 8 9.26 < 0.01a proved detection of subtle pneumothorax [18].
Normal finding versus pneumothorax 1 2.73 0.14 There were limitations to this study. Only
a Statistically significant difference. three radiologists from a single site were used
to select user preferences. The statistically
significant difference between radiologist
TABLE 2: Predicted Ratings for Lowest Brightness preferences (p < 0.01) (Table 1) indicates
that image-display preference is a highly per-
Narrowest Narrower Narrow Middle Wide Wider Widest
Latitude Latitude Latitude Latitude Latitude Latitude Latitude
sonal choice. In addition, only one vendor’s
Contrast (0.44) (0.50) (0.56) (0.70) (0.92) (1.09) (1.46) CR equipment was used. The results cannot
Highest (4) –2.5 –2.5 –2.1 –1.9 –1.8 –1.8 –2.0
be extrapolated to other types of monitors,
uncontrolled viewing situations, and other
High (3.5) –2.1 –2.0 –1.8 –1.7 –1.7 –1.9
vendors’ CR and digital radiography systems.
Low (3.1) –2.1 –1.9 –1.8 –1.8 –1.9 Direct extrapolation of the findings of
Lowest (2.5) –2.3 –2.2 –2.2 –2.4 this study to current clinical practice as a de-
Note—Values in parentheses are actual latitude and contrast settings used. Peak preference range is displayed partment transitions to soft-copy interpreta-
in boldface, and the values are not significantly different from the highest rated value. Latitude = Δlog tion is problematic given the limitations of
(exposure), detail contrast = Δdensity / Δlog (exposure).
this study. Setting up and performing exper-
iments such as ours require access to raw
TABLE 3: Ratings for Middle Brightness image data, imaging physicists, and time.
To aid clinical departments in the transition,
Narrowest Narrower Narrow Middle Wide Wider Widest radiologists should encourage the vendors
Latitude Latitude Latitude Latitude Latitude Latitude Latitude
Contrast (0.44) (0.50) (0.56) (0.70) (0.92) (1.09) (1.46) of digital imaging equipment and PACS
workstations to develop a library of cases
Highest (4) –0.1 0.0 0.1 0.2 0.2 0.1 –0.3
that include various ages, body parts, and
High (3.5) 0.0 0.1 0.2 0.2 0.1 –0.3
disease processes. When new equipment is
Low (3.1) 0.0a 0.0 0.0 –0.1 –0.5 installed, radiologists can review the cases
Lowest (2.5) –0.6 –0.6 –0.7 –1.0 to find their personal preferences.
Note—Values in parentheses are actual latitude and contrast settings used. Peak preference range is displayed The results of this study establish baseline
in boldface, and the values are not significantly different from the highest rated value. Latitude = Δlog soft-copy display parameters for neonatal
(exposure), detail contrast = Δdensity / Δlog (exposure). chest CR. These parameters are clearly differ-
a Reference T-MAT G (Eastman Kodak) image processing.
ent from those for the screen-film hard-copy
laser-printed images to which radiologists
have become accustomed for interpreting CR
TABLE 4: Ratings for Highest Brightness
images. Scientific research on image process-
Narrowest Narrower Narrow Middle Wide Wider Widest ing and dose reduction requires establishing
Latitude Latitude Latitude Latitude Latitude Latitude Latitude
Contrast (0.44) (0.50) (0.56) (0.70) (0.92) (1.09) (1.46)
baseline image processing. Future improve-
ment in image processing and studies on the ef-
Highest (4) 1.2 1.2 1.3 1.3 1.1 0.9 0.4
fects of dose reduction on detection of disease
High (3.5) 1.1 1.1 1.1 0.9 0.7 0.2 processes can be conducted with controlled
Low (3.1) 0.8 0.8 0.6 0.4 –0.1 imaging parameters for reducing and eliminat-
Lowest (2.5) 0.0 –0.1 –0.3 –0.8 ing confounding factors in statistical analysis.
Note—Values in parentheses are actual latitude and contrast settings used. Peak preference range is displayed In conclusion, this study showed that pedi-
in boldface, and the values are not significantly different from the highest rated value. Latitude = Δlog atric radiologists prefer high brightness, high
(exposure), detail contrast = Δdensity / Δlog (exposure). detail contrast, and a narrow to middle lati-
tude image processing for viewing neonatal
chest CR images compared with a soft-copy
adult chest radiographs is much higher, in the graphs. A wider-latitude image compresses control image on which tonal characteristics
range of 120–140 kVp. The higher peak kilo- the range of optical density for optimal dis- and brightness are mapped to yield an optical
voltage used for adult chest radiographs re- play of soft-copy chest images of adults. density of approximately 1.65 in the lung re-
sults in lower contrast and a wider range of The presence or absence of pneumothorax gion. The presence or absence of pneumotho-
optical density than on neonatal chest radio- did not significantly affect viewer preference. rax did not affect viewing preferences.

AJR:188, April 2007 1143


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