Amorphous selenium direct-conversion x-ray detectors have been used successfully for full field digital mammography (FFDM) and digital radiography (DR). Such detectors characteristically exhibit high spatial resolution and conversion efficiency that is a function of the applied electric field. At an electric field of 10 volts per micron, about 50 electron volts of photon energy are required to generate an electron-hole pair in a typical amorphous selenium x-ray conversion layer. At FFDM and DR imaging x-ray energies each absorbed photon can generate only about 250 to 1000 electron-hole pairs. Each absorbed x-ray photon is only contributing 4 x 10-17 to 1.6 x 10-16 coulombs of imaging charge. On the noise side, detectors operating at room temperature have a basic thermal (kTC) noise of 300 to 600 electrons per pixel from the image charge storage capacitor. Electronic noise from the front-end charge amplifier is also amplified by one plus the ratio of the TFT data line capacitance and the feedback capacitance of the charge amplifier. Medical imaging applications must therefore employ low noise thin film transistor (TFT) arrays, low data line capacitance and low noise charge integration amplifiers to achieve high signal-to-noise ratio (SNR) and detective quantum efficiency (DQE). To achieve quantum-noise limited imaging results with the lowest practical x-ray exposure dose, it is desirable to include an additional low-noise gain stage in the x-ray conversion layer. This is particularly important for the application of dynamic imaging or for tomosynthesis where x-ray dose per frame is very limited. A new structure for an amorphous selenium detector that employs an internal biased gain grid to cause avalanche-gain within the x-ray conversion layer is being proposed. A signal charge amplification of at least 10X can be achieved without introducing excessive noise. Quantum-limited image detection should then be attainable for even very low exposures.