PURPOSE: The accurate prediction of x-ray spectra under typical conditions encountered in clinical x-ray examination procedures and the assessment of factors influencing them has been a longstanding goal of the diagnostic radiology and medical physics communities. In this work, the influence of anode surface roughness on diagnostic x-ray spectra is evaluated using MCNP4C-based Monte Carlo simulations. METHODS: An image-based modeling method was used to create realistic models from surface-cracked anodes. An in-house computer program was written to model the geometric pattern of cracks and irregularities from digital images of focal track surface in order to define the modeled anodes into MCNP input file. To consider average roughness and mean crack depth into the models, the surface of anodes was characterized by scanning electron microscopy and surface profilometry. It was found that the average roughness (Ra) in the most aged tube studied is about 50 pm. The correctness of MCNP4C in simulating diagnostic x-ray spectra was thoroughly verified by calling its Gaussian energy broadening card and comparing the simulated spectra with experimentally measured ones. The assessment of anode roughness involved the comparison of simulated spectra in deteriorated anodes with those simulated in perfectly plain anodes considered as reference. From these comparisons, the variations in output intensity, half value layer (HVL), heel effect, and patient dose were studied. RESULTS: An intensity loss of 4.5% and 16.8% was predicted for anodes aged by 5 and 50 microm deep cracks (50 kVp, 6 degrees target angle, and 2.5 mm A1 total filtration). The variations in HVL were not significant as the spectra were not hardened by more than 2.5%; however, the trend for this variation was to increase with roughness. By deploying several point detector tallies along the anode-cathode direction and averaging exposure over them, it was found that for a 6 degrees anode, roughened by 50 microm deep cracks, the reduction in exposure is 14.9% and 13.1% for 70 and 120 kVp tube voltages, respectively. For the evaluation of patient dose, entrance skin radiation dose was calculated for typical chest x-ray examinations. It was shown that as anode roughness increases, patient entrance skin dose decreases averagely by a factor of 15%. CONCLUSIONS: It was concluded that the anode surface roughness can have a non-negligible effect on output spectra in aged x-ray imaging tubes and its impact should be carefully considered in diagnostic x-ray imaging modalities.