Study guide to

Ultrasound Physics Registry Review

Melessa Cizik RDMS, RVT

www.myultrasoundtutor.com
2020 edition
Table of Contents

Physics principles
Properties of sound……………………………………………………….……..….1
Properties of the medium ..………………………………………………………..3
Sound propagation in tissue .………………………………………………..……4
Resolution……………………………………………………………………………8

Transducers
Construction and function…….………………………………………………….11
Types……………….………………………………………………………….……13

Imaging Principles and Instrumentation

Pulse-echo principle and modes.………………………………………………..17
Image processing and Instrumentation ……………………….…………….….18
Harmonics..…………………………………………………………………………24
Artifacts .……………………………………………………………………………25

Doppler and Hemodynamics

Doppler principles and Instrumentation ……………………….………………28
Hemodynamics ……………………………………………………………………34

Safety and Quality Assurance

Bioeffects and safety ……………………………………………….……………39
Quality Assurance ………………………………………..………………………41
New technologies ………………………………………..………………………43
 Ultrasound Physics Review
Physics principles (15%)

Properties of sound

Sound is a mechanical, longitudinal wave. Longitudinal means parallel from sound

source. Mechanically moves through medium by vibration of molecules or physically
changing pressure, compressions (high pressure) and rarefactions (low pressure)
One complete cycle = 1 compression and 1 rarefaction

Frequency # cycles per second Hz ƛ = wavelength

Wavelength length of one cycle mm ƛ= c c = prop speed
f
Period time of one cycle µs f = frequency

Relationships
Direct: If one increases, the other increases and vice versa (go together)
Inverse: If one increases, the other decreases (opposites)

Wavelength depends on 2 things - frequency (determined sound source)

and propagation speed (determined by medium)
Wavelength and frequency are inversely related
Wavelength directly related to propagation speed
Mediums with fast prop speed = longer wavelength
Mediums with slower prop speed = shorter wavelength
Propagation speed is NOT affected by either freq or wavelength

Think about the terms! Physics is very literal. If you do not know what something means, think about
what it means in everyday language.
Example: frequency means how often something happens in a period of time. So in ultrasound, it
means how many waves occur in one second

Common unit pre xes

Different types of sound
kila(k) = thousand
• Infrasound < 20 Hz mega(M) = million
• Audible sound 20-20,000 Hz centi(c) = 1/100
• Ultrasound >20,000 Hz milli(m) = 1/1,000
• Diagnostic US 2-20 MHz micro(µ) = 1/1,000,000

Simply exchange the word with the pre x

Example: 20,000 Hz = 20kHz

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Measuring energy
Power- rate of ow of energy (Watts)

Intensity- power/area (Watts/cm²)

Example: 40 Watt light bulb. That’s power. Imagine the 40W bulb in a small closet vs it in a
large room. Which appears more intense? The closet = smaller space = greater intensity.
Increase the space = decreases the intensity

Amplitude- height of pressure wave (MPa megapascals). Hydrophone: used to measure the
pro le of US beam by measuring the pressure amplitudes (intensities)

These describe the strength of the energy. These are NOT related to frequency/wavelength/period.

Intensity Decibels

Decibels 1000 30

100 20
In US, we use deciBels to describe the relative intensity of our wave.
We only care about what happened to the intensity, not the value. 10 10

In other words, to describe HOW much our intensity has changed, we use 4 6
deciBels. 2 3

When we multiply our intensity by 2 = rise of 3 dB (increase or gain) 1 0

1/2 -3
If we half the intensity = loss of 3 dB (decrease or attenuation)
1/4 -6

Half-value layer= when sound reaches 1/2 its original intensity = -3dB 1/10 -10

1/100 -20

1/1000 -30
Q: A reduction of 6dB means the intensity is reduced by how much?
(we will see more about dB affects us when we look at attenuation)
A: Losing 6 dB corresponds to intensity reduced to 1/4. So if sound attenuated 6dB, that means it is
now 25% what is was originally

Q: Adjusting overall gain from 25dB to 28dB will cause what affect to the intensity of the echoes?
A: There was an increase of 3dB which means the intensity was doubled.

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Properties of the Medium
Propagation speed
Speed of sound in a medium. Totally dependent on medium only.
Before we discuss how sound interacts with the tissue, we have to rst understand the
properties of our tissue. So forget about sound for a moment.
Propagation speed is a property of the medium. It will only change if the medium changes.

In soft tissue 1.54 mm/μs or 1540 m/s ALWAYS

It is based on a mediums stiffness (how hard) and density (how packed together) Stiffness is
same as BULK MODULUS. Each medium has its own propagation speed.

Elasticity and Compressibility stiffness prop speed

bulk modulus prop speed
Opposite to stiffness!
Think of something elastic and compressible.
Ex- marshmallows are very compressible and NOT stiff. compressibility prop speed
So if elasticity increases > stiffness decreases elasticity prop speed

Propagation speed is NOT affected by frequency or wavelength

Based on the formula, technically density and prop speed are inversely related. But
generally, mediums that are dense are also more stiff, that means prop speed
increases.

Medium Density Prop Speed

Air 1.2 330

Fat 920 1450 Increasing propaga on speed

Water 1000 1484
Increasing density
Liver 1060 1570

Muscle 1070 1580 Increasing wavelengths

Bone 1800 4080

Each medium also has its own IMPEDANCE value. To impede means to obstruct or hinder.
∴ Impedance is a measure of resistance (Rayls). It is a property of the medium, so …
It is only dependent on the medium.

Z = pc density impedance
Z = impedance prop speed impedance
p = density
c = propagation speed
Impedance is NOT affected by frequency or wavelength

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HOW DOES THIS AFFECT US?

When sound encounters an interface (tissue change), 2 things can happen: some of the
sound can be re ected (bounce back) and the rest continues traveling or is transmitted.
There will only be a re ection if there is difference of impedance or impedance mismatch.

REFLECTION = IMPEDANCE MISMATCH

No mismatch (equal impedances) = NO re ection = 100% transmission

Amount of re ection is proportional to the change in impedance levels.

Small change in impedance = small amount re ection
Greater the impedance mismatch, the greater the re ection.

Typical re ection coef cients in soft tissue imaging: < 0.1% and over 99% transmitted.
That means the majority of the sound is transmitted with soft tissue imaging. And that’s
what we want! The more similar they are, the more will transmit

** Soft tissue to air/lung interfaces = greatest energy re ection**

Think about what that means for you. What happens when you scan on bone or air? What do you see?
Not much. Why? Think about how different bone and air are to soft tissue. Big difference in tissue means
big impedance mismatch = big reflection and that means nothing left to transmit.

Attenuation

Weakening of sound. Depends on medium, different mediums will weaken the sound
differently (as we learned with bone or air)
Average rate of attenuation in soft tissue 1/2 dB/cm/MHz (decibels=change in intensity)
Frequency and attenuation are directly related. Increase freq = increase attenuation

Attenuation coef cient

How much is the frequency going to attenuate per cm. Simply half the frequency!!

Example: Frequency and Attenuation

4 MHz will attenuate 2 dB/cm Directly related
8 MHz will attenuate 4 dB/cm Inc Frequency = Inc attenuation = Less penetration
Double the frequency = Double attenuation Dec frequency = Dec attenuation = More penetration
The more sound attenuates, the weaker it gets which means
it will not be able to travel as deep

Apply to how you choose frequency. Imagine: You have a 4 MHz, 8 MHz, and 12 MHz to choose from.
Do you always choose the highest one you have? No.
Why not? The 12 MHz cannot penetrate or travel as deep as the 4 MHz. All because of attenuation! We
choose a frequency that is able to reach the depth we need.

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HOW DOES SOUND ATTENUATE?

Absorption: energy is lost as it is converted into heat.

Re ection: Main source of attenuation. When sound encounters tissues with different
impedances. Some energy gets re ected back, some is transmitted. The following
are different re ector types:

• Specular re ector: large, smooth interface

Re ected back to us if 90 degrees incidence.
*** Angle of incidence is important! It will determine where the
re ection will go (not if it will occur)

Normal incidence
90°
Right angle
Perpendicular

RESULTS : since 100% of re ections come back to transducer

when at normal incidence, then boundaries on US appears
strong, bright and clear.
(ie- diaphragm, large cyst, renal capsule, etc)

• Diffuse re ector: large, rough interface.

Re ected in all directions, regardless of angle of incidence.
Angle does not matter

RESULTS : not all re ections return back to transducer,

boundaries appear ill-de ned, shadowy, and unclear

Scattering: small interfaces. Size is equal to one wavelength,

re ections are scattered in all directions, creating softer re ections and
appearance. Scattering is responsible for the appearance of organ
parenchyma. (ie- liver, pancreas, placenta echo texture)

Rayleigh’s scattering: when the interface is smaller than one wavelength,

the scattered re ections are equal in all directions. (ie- red blood cells)

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Refraction: when the sound beam changes direction or bends as it transmits from one
medium to the next. Change to the angle of transmission

2 things are required

Oblique incidence
AND
Different propagation speeds

If normal incidence = NO refraction

If identical prop speeds = NO refraction

If NO refraction takes place = angle of transmission is equal to the angle of incidence

If there is an impedance mismatch, then re ection will also take place. But re ection and
refraction are very different.
Snell’s Law: relationship between the incident angle and refracted angle when the two
mediums have different propagation speeds and oblique incidence
Critical angle: When the US beam is extremely oblique, C2 > C1, and the angle of
refraction is parallel with medium ∴ NO transmission of sound

Divergence: same power spread over larger area (far eld).

Intensity reduction.
Diffraction is a form of divergence and also reduces
intensity

Identify the principle. When given a question regarding basic sound principles, first identify what it is
asking. Is it about reflection? Transmission? Refraction? Once you know what key principles are involved in
the question, then you’ll be able to solve what will or will not happen.

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Pulsed Ultrasound Parameters

Pulsed US generates pulses of 2-3 cycles only. Pulse echo principle = sends pulse then
waits for echo. Uses listening time to know the location of the re ection

PRF: pulse repetition frequency = number pulses in 1s. Depends on depth since the
machine must wait for the echo before it sends the next pulse (to avoid range ambiguity).
The longer the distance the pulse must go, the longer it must wait means less pulses per
second. If PRF is too high, machine will not know the location or depth. Inversely related
to depth
Depth PRF Depth PRF

PRP: pulse repetition period = time between beginning of 1 pulse to beginning of the next
pulse. Includes listening time or wait time. So inversely related to PRF and directly related
to depth
PRF PRP PRF PRP

SPL: spatial pulse length = length of one pulse. Depends on frequency

PD: pulse duration = time for one pulse to occur. Depends on SPL

In Diagnostic US- PRF is in kHz

Duty Factor

“on duty”

Fraction of time the machine is actively working and sending pulses. Only
things that change the time the machine is pulsing will change DF

PRF DF PD DF

PRP DF PRP DF

depth PRF DF

DF of Pulsed US only 0.1-1.0%

Over 99% of time = listening

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RESOLUTION

Resolution is the machine’s ability to detect and display accurately.

2 main types of resolution: SPATIAL(space) and TEMPORAL(time)

Spatial resolution : the machine’s ability to distinguish between 2 closely spaced objects
and display them separately. The spatial resolution will be measured in space or distance
(mm)

Axial and Lateral

Axial = vertical
Lateral = horizontal

Axial = 1/2 SPL

2 vertical objects parallel or along axis of pulse

LARRD (longitudinal, axial, radial, range, depth)

Minimum distance 2 vertical objects must be separated by to be resolved = 1/2 SPL

In this example:

SPL of 1.8mm = Axial res of 0.9mm

The 2 objects are separated by 1mm. They are
separated by the minimum distance = resolved!

SPL of 2.2mm = Axial res of 1.1mm

The same 2 objects no longer meet the
requirements = blurred together vertically

Even though 2 echoes are produced, the

echoes are blended because the pulse is longer

GOAL: shorten the pulse

✦ Increase frequency
Decreases wavelength = decreases pulse

✦ Damping/backing material
Reduces ringing of crystal = shortens the pulse

✦ Wide Bandwidth = shorter pulse (lo Q)

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Trade off

When you gain something by giving something else up. All resolutions have a trade off

Main way to improve axial = increase frequency. Do you always choose the highest
frequency you have? NO. Because you will not be able to scan deeper

Now think about when you choose a lower frequency… what do you gain? imaging
depth or penetration… what do you give up? axial resolution

Axial resolution for penetration

How to choose? The highest possible frequency with adequate penetration

Lateral = Beam width

2 horizontal objects perpendicular to beam

LATA (lateral, azimuthal, transverse, angular)

Two objects must be separated by a distance greater than the beam width

As long as the 2 objects are hit by their own beam, then

they will produce separate echoes and then machine will
display both of them. Not resolved = blurred horizontally

The smaller the cuts are through the tissue, the more likely
they will be seen separately. Notice what happens when
line density increases (increase the # of scan lines) = the
beams are smaller. Closer lines = better lat res

GOAL: narrow the beam

✦ Focusing : Position and Number

At the area of interest (target within near eld)
Multiple focal zones = overall beam narrowing

✦ # Scan lines / scan line density

Scan lines = beams. Increase line density = smaller beam size

✦ Sector angle
Decreasing sector size = increases line density

✦ Transducer choice
Sector FOV ( eld of view) = lower line density in far eld, lat res worsens

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Temporal = Frame Rate
Determined by time it takes to make the frame (# frames per second)

Adequate FRAME RATE in order to visualize 2 separate events (frames) in time. Basically
the machine needs to ‘keep up’ with whatever is going on in the body so that it can
display the events accurately. If the frame rate is poor, the images appear to be blurred
together giving a slow motion effect.

Frame rate is determined by the amount of work the machine has to do or time it needs to
produce the frame. Anything that will add more work or more time = slower frame rate

GOAL: Faster frame rate

✦ PRF/depth
Higher PRF = faster FR. Decrease depth to increase PRF

✦ Reduce # transmit focal zones

Multiple pulses per scan line = more work
Reduce # focal zones to improve FR

✦ # Scan lines / scan line density

Scan lines = work. More scan lines = slower FR
Reduce scan lines/line density to improve FR.

✦ Sector angle
Decreasing sector size = reduces # lines and smaller frame
Less work = faster FR and better lat res

Trade off

Lateral resolution is improved by more information, more detail. Temporal resolution is

worsened by more info, more detail. When we improve one, the other is degraded

Lateral resolution for temporal

How to choose? Optimize your lateral resolution without sacri cing the frame rate.

Some exams require faster frame rates.

Cardiac = highest frame rates since heart is constantly in motion. MSK and small parts
usually have minimal motion = frame rate can be lower and lateral resolution optimal
** More motion involved, the faster the frame rate needs to be.

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Transducers (16%)
Act as both transmitter and receiver
Transducer element converts one form of energy into another electrical mechanical

Piezoelectric (literally pressure-electric)

When electric voltage is applied, crystal vibrates (becomes mechanical) >> produces pressure
When pressure is put onto crystal >> crystal produces electricity (converts back to electric)

Crystal materials : PZT - lead zirconate titanate (man made ceramic crystal) or Quartz
Curie temperature/point: @ 400°C the point the crystal loses its piezoelectric properties

Operating frequency is determined by the thickness of the crystal (typically 0.2- 1.0mm)

Crystal thickness = 1/2 wavelength

Since wavelength and frequency are inverses, then crystal thickness and frequency
are also inversely related
Thinner the crystal, higher the frequency

Lens
Mechanical means of focusing to reduce divergence.
Mechanical focus = lens, curved element, or mirrors
Fixed focal point with all mechanical ways to focus
(Fixed means we cannot control)

Impedance Matching Layer

A layer at the transducer face that matches the impedances. We need to “match” the two
impedances so that most of the beam can be transmitted easily into the body. The Z value
of the matching layer is halfway between the Z of the crystal and the Z of soft tissue.

Purpose of the matching layer is the same as the coupling medium or gel.
Aids transmission of sound into the body by reducing re ection.

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Backing/Damping material
When the crystal is hit with electricity it rings like a cymbal on a drum set. If nothing is
done, the cymbal will ring on and on. The stop the ringing you can put your hand on the
back of the cymbal. That is what backing does, it stops the ringing and shortening the
pulse. We do not want long uncontrolled pulses.

For Pulsed US : we want 2-3 cycles only

Backing and damping shortens the pulse

Bandwidth
The range of frequencies.
The size of the pulse determines the bandwidth.

Short and Fat Tall and Skinny

Short pulse/wide BW Long pulse and narrow BW

* Center operating frequency = MAIN operating frequency

Bene ts of wide BW- since larger BW means shorter pulses. Wide BW = better axial res

Quality Factor or Q-Factor: quality of frequency of the transducer. Does NOT mean
quality image!
Bandwidth and Q factor are inversely related.
Q-factor = resonant freq Narrow BW = Hi Q
bandwidth Just main frequency= clean
Wide BW = Lo Q
Multiple frequencies and good axial res

Do we want Hi Q transducers?
Think about this. If we choose Hi Q : hi Q = narrow BW and that means longer pulses. Longer
pulses have poor axial resolution. So we prefer Lo Q

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Beam Characteristics

Fresnel Zone: Near eld

The point from the transducer face to the point of divergence. If it is a
focused transducer, then the beam is converging in the near eld.

Fraunhofer Zone: Far eld

Beam divergence.

Focal zone/point
The area the beam reaches its smallest diameter

What in uences beam shape in single element transducers?

Crystal size or diameter Smaller diameter gives a narrower beam, but shortens the near
eld. Larger diameter = longer near eld

Frequency Increasing freq lengthens the near eld ∴ less divergence.

Both are directly related to the length of the near eld (depth of focus)

Longer near eld = larger diameter and higher frequency

Transducer Types

The whole idea of real-time imaging transducers is to send multiple cuts or scan lines
through the medium in order to produce a frame. There are mechanical and electronic
(array) transducers. All modern day transducers are arrays.

Mechanical: “moving parts”. The piezoelectric crystal is mechanically

moved from side to side, sending out scan lines across the face of the
transducer. Since the whole transducer is mechanical, the focusing is
only done mechanically ( xed focus).

Rotating or oscillating mechanical transducers produce a sector eld

of view (swinging or pendulum like motion)

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Array (electronic): Imagine the inside of a digital watch, no moving parts, computerized or
programmed. The goal is the same as the mechanical, to re off a sequence of scan lines
across the transducer face. But the crystals do not move. Instead there are multiple of
crystals lined up in a row: 128-256 crystals. These crystals are electronically red or set off
in a series individually or in groups across the face of the transducer in a sequential
manner.

Beam Former sets the order and timing of the sequence

Notice in the diagram to the left. The elements are

organized into sequential groups. Each group is one
scan line/one beam. Together these elements in a
group form the aperture.
Increase aperture = increase beam size

Huygens’ Principle

Basically states that each wave produced by the elements

will combine or link together to form a wavefront. The
wavefront is a single beam of sound. This is what allows us
to manipulate the beam shape electronically by focusing
and/or steering.

Electronic Focusing and Steering

In addition to mechanical focus (lens), array transducers can also do electronic beam
focusing. Some arrays can also do electronic steering. Both work by using time delays.
Since all the elements in a group will be linked together to become a wavefront, they
affect each other. Just as a marching band can be guided in different shapes and directions
by timing the actions of the people, the shape and direction of the beam can be
manipulated by changing the timing or sequence of the elements. This is done by the
beam former

Electronic Focusing
Time delays on the center elements >> shape of the beam becomes U shaped Beam
converges or get smaller as it travels. Adjustable focal position
Focal depth/position determines timing. Change position = change timing
Multiple focal zones: One pulse is needed for each focal point. Mult focal points
means we will need multiple pulses
(ie- 3 focal points = 3 pulses per scan line)

All array transducers can do dynamic / electronic / transmit focusing because they
all have a series of elements.

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Electronic Steering / Phasing

Same principle as focusing except the time delays are now across the group of
elements to guide it in that direction = phasing. The beam direction will go
towards the side the delay is on.
Not all array transducers are capable of electronic steering.
ONLY PHASED ARRAYS

The beam goes in the direction of the delay.

Focusing : delay in center, beam focuses towards the center

Steering : delay on side, beam steered to the side

Slice thickness AKA elevational dimension

Thickness of the beam.

Beam is 3 dimensional. Like beam width, the narrower the better.
Like a sharp knife, a thin slice thickness is able to “slice” through tissue clearly, especially
small echo free structures. When the elevational resolution is poor (thicker): unable to
clearly display small cystic objects, blends surrounding echoes into structures.

1 row of elements 1D
Typical array transducers have one row of elements.
One row = mechanical focus = xed (curved element, lens, or mirror)
Unable to control elevational resolution

Multi rows 1.5D and 2D

Transducers capable of 3D or 4D imaging, several rows of elements.
Having multiple rows, dynamic elevation focusing is possible and
better elevational resolution. 2D has more rows than 1.5D = better
beam control, thinner slice, and better eld of view. 2D can also do
3D/4D imaging.

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Linear : High frequency >7MHz Small parts, Vascular, MSK

Aka Linear sequential array. When scanning super cial structures that
require high resolution imaging but do not require penetration. Higher
frequencies provide improved axial resolution but reduced penetration. Line
density is maintained in the far eld. Rectangular display

✴ Linear phased array

Looks the same as linear probe. Capabilities of electronic beam
steering (phased). Gives option of wider FOV as a trapezoid display.

Curvilinear : 2-6 MHz Abdomen, OB, Gyn, Pelvis

When exam requires larger FOV and penetration. Usually lower

frequencies since large depth is normally required. Always choose
the highest possible frequency but with adequate penetration.
Sector display (elements arranged in curve. Does NOT steer)

✴ Endocavity probes AKA tightly curved linear

6-8 MHz (Transvaginal, Transrectal) Allows scanning closer
to the area of interest, higher frequency transducer can be
used, resulting in superior spatial resolution. Very low line
density in far eld. Lateral resolution degrades with depth.

Phased Array : 2.5-4 MHz Echo

Small footprint with wide FOV. Chosen for echo exams since views are
obtained intercostally and heart is larger organ which requires wide
FOV.
Pie shaped display (sector). Obtains FOV by phasing (steering)

Annular array: no longer used but here’s what you need to know:
Concentric rings of elements (target sign) produces a symmetrical beam shape (cone or
cylinder). Very poor elevational resolution. Electronic focusing but mechanical beam
steering. Sector FOV

Think about which transducer and frequency you choose for each exam type.
What? When? Why?
Example: Why would you choose a low frequency curved for an abdomen exam on a large patient? Why
would you not choose a linear? How would you choose what frequency within the range?

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Imaging Principles and Instrumentation (28%)

Pulse echo principle: When a sound wave encounters an interface of 2 different

impedance levels, part of the pulse is re ected and the rest is transmitted. The machine is
able to determine the distance of the re ector based on the time the echo takes to return
to the transducer. 1st use of pulse-echo principle was with SONAR (SOund NAvigation
and Ranging) in WWI. 1st contact form of US- B scanner.

A-mode (amplitude mode)- Displays re ections as height of the spikes. Strong

re ections (signal amplitudes) would be plotted as a tall peak, low intensity as
smaller peaks, and no echoes as a at line. Graph of received voltages
representing the echoes and plots them according to their received time is plotted
by oscilloscope.
Time corresponds to distance = distance measurements can be made.
No longer used on modern machines.

B-mode (brightness mode)- A-mode info converted into dots of varying brightness
and displayed on video screen. The higher the amplitude, the brighter the dot.
Tall spike = bright dot … Small spike = dark dot … Flat areas = echo-free. Uses
pulse echo principle, distance can be measured.
Originally bi-stable (only black and white) now grey scale (shades of grey)

M-mode (motion mode)- Detects the location of all

structures along a single scan line (line of sight) and displays
it according to time. If location changes with time =
MOTION. Displays stationary objects as well as moving
objects. The purpose is to see the motion of the moving
targets.
Distance can also be measured

Range Equation

Allows us to use the “time of ight” or round trip time Distance = RT time x prop speed
to calculate the distance travelled. 2
Speed and time needed

13 microsecond rule
For every 13µs of RT time = re ector is 1cm deeper

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Pulse Echo Processing

PULSER controls the electric voltage that will be sent to transducer. Power and Rate

Power
Adjusting the Output Power will adjust the power of the voltages used. Increasing the
strength of the voltages will in turn increase the intensity of transmitted US pulse.
Result to image = increases overall intensity of the echoes (brighter image)

To increase brightness of image… do we always increase output power rst? Why not?

Rate
Pulser also controls the rate that pulses are sent. Adjusted when tech changes imaging
depth = changes PRF. In order the change PRF, rate of voltages must also be changed.

BEAM FORMER receives these pulses of voltage and programs order and timing of
sequence. Controls beam shape, focusing and direction of beam (by time delays)
Anything that changes shape of beam or scan lines will be accomplished using the beam
former. Example: line density, sector angle, multiple focal zones, steering.

TRANSDUCER converts voltage into pressure. Sound transmitted into body, echo
produced. Echo returns to transducer as a pressure wave. When hits crystal, pressure is
converted back into electric signal. Sent to machine for processing!

What naturally occurs as sound travels through tissue? It attenuates. It loses energy. When
the echo is produced, that echo (which is still a sound wave) now has to travel through the
same tissue. Echo also attenuates. VERY WEAK!

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PRE-PROCESSING

RECEIVER receives the returning signals and knows that they have been weakened by
attenuation and compensates by amplifying the received echoes.
Compensation, ampli cation, gain all refer to this same process

How do we control?

Overall gain- Increases overall brightness of ALL echoes

(received signal amplitudes)

TGC (time gain compensation)- attenuation worsens with

depth. TGC allows us to compensate for loss with
increasing depth ⇉ RESULT: even brightness level across
the screen

Q: How would your image appear if you had no TGC??

A: Brighter at top with gradual darkening down the screen.
Why? Because attenuation increases with depth

Remember decibels?? Let’s bring it full circle.

Say your current gain setting is at 25 dB and you increase it to 28dB. What is the overall effect to
the intensity of the echoes? Doubles (3dB gain = double intensity) pg 2
When you make that change, what does increasing the gain actually do? Only increases received
info = nothing changes in the transmitted sound = SAFE!

The SIGNAL PROCESSOR is going to clean up the

signal and turn it into something machine can display.
Like a processing plant, we start with raw material. Goal
is to have a clean digital signal ready to be displayed

Recti cation Turns all negative waves into positive. Not

operator adjustable

Rejection Filters or eliminates noise or low level

echoes. Operator adjustable

Enveloping/demodulation Turns signals into a

“package” of a video signal. Not operator adjustable

Compression After enveloping, the signal is a value too large for

the machine to display. Signal information is compressed into a
value within the dynamic range and decreases difference between
largest and smallest signals. Operator adjustable

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Dynamic Range

Number of shades of grey. Shades of grey represent the signal intensities. So dynamic range
can also be de ned as the minimum(black) to maximum(white) displayed intensities or the
ratio of the smallest to the largest signal amplitudes.

Decreasing DR = less shades of grey = higher contrast

Increasing DR = more shades = softer image/less contrast

Make it practical!
Imagine yourself in the following scenarios

Imaging the liver: Anteriorly appears normal echogenicity but distinct

darkening in the far eld. What should be adjusted? Gain or TGC? Why?

Entire image appears to be very black and white = high contrast. What do
you change and how? Would overall gain help? Output power? Why not?
Dynamic range?

Contrast Resolution
The ability to distinguish similar structures with slightly varying grayscale.
GOAL: subtle changes in shades of gray, smoother imaging

Improved by Dynamic Range, Persistence, Compounding, Grey scale maps

Additional pre-processing functions (all of the following are operator adjustable)

Edge Enhancement: applies lters to emphasize changes in brightness in the area around
the edge. Increases contrast at the boundary ∴ appears sharper

Persistence: Frame Averaging. Echo info is accumulated over a longer period of

time and combined. Allows for subtle tissue texture differences. Improves
contrast resolution but reduces frame rate. Should be turned off or low when
need high frame rate.
DOPPLER/COLOR: subtle doppler shifts enhanced. Inc to enhance slow ow

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Image Compounding to enhance image quality

Frequency Compounding (common names: SRI, XRES, MView, SCI, SonoHD)

Speckle Reduction Imaging. Identi es strong and weak signals pixel by pixel.
Eliminates the speckle leaving cleaner, smoother image. Improves contrast
resolution

Spatial Compounding (SonoCT, CrossBeam, XView, SonoMB, CRI)

Scan lines are directed in multiple directions by phasing (beam steering). Views
tissue from multiple angles, reducing artifacts such as shadowing and enhances
edges. Improves contrast resolution
Reduces frame rate.
When imaging a structure that a shadow is expected such as a stone, spatial
compounding must be turned off

Zoom: to magnify areas of interest and small structures. Write and Read zoom

❐ Write (real-time) is pre-processed. Improves image quality: resolution and line

density. Best way to zoom.
❐ Read is post-processed. Can be done on frozen image. Only enlarges stored data/
larger pixel size. Image quality is degraded

Extended eld of view

Enables a panoramic image by moving probe across the patient. Multiple image frames are
captured and matched by location. (just like taking a panoramic with your iPhone). It’s
able to track probe motion and reconstructs the composite image. Allows for better
visualization and measurement of larger structure that cannot t in the traditional eld of
view

POST-PROCESSING

Image Processor takes the value of the signal and assigns it to a location (pixel=picture
element) and displays it as a level of brightness at the correct depth and location. Grey
scale maps are used to display levels of grey. Can be chosen by operator.

Image Memory/Scan converter stores the sequentially acquired and processed image
frames. Rapidly sent to the display for real-time imaging.
> 30 FPS (frames per second) is optimal for real-time imaging. > 15 FPS to be icker free.
Freeze image: 1 frame is frozen and displayed for permanent storage of still images.
Digital video clips of multiple frames can also be acquired and stored. Real time clips can
be saved and stored. Used for dynamic studies such as echo.

CINELOOP Numerous frames are temporarily stored in image memory. On frozen image,
you can “rewind” to nd the desired frame and permanently store.

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DISPLAY frames in memory sent to display

CRT Cathode Ray Tube Made of 525 horizontal scan lines. Signal must be converted
back to ANALOG. (Digital to analog converter) Uses electron gun that shoots a stream of
electrons to “paint” the image on the screen. When the electrons hit the phosphor coating
on the inside screen, they glow

Modern day Digital scan converter. We use computer screens or at screen monitors
(LCD monitors). Digital is based on binary system.
8 bits = 1 byte = 1 pixel (grey scale image)

STORAGE
Hard copy: lm, paper
Optical: CD, DVD, blue ray (greatest capacity)
Digital Storage: PACS network

PACS Picture Archiving and Communication Systems

Easy management of work ow. Physicians can almost instantly access exam images and
documentation from remote locations. Not relying on hard copy = reduces loss of images
and repeat exams. Study intergraded with all other associated data and images with report.

Format: DICOM (Digital Imaging and Communications in Medicine)

DICOM is the protocol standard for communicating imaging data between the US
machine and workstations. PACS is the network and DICOM is how it communicates

QA workstation: ✓ pt info (tech to review)

Additional PACS components:

Query - search for pt on US

machine ARCHIVES

Worklist - allows you to select pt

and will automatically populate
pt info into US machine Reading workstation (Radiologist)

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Console Settings and Image Optimization

This section is to help you be prepared for SIC questions on the ARDMS. It will also aid you in
applying your knowledge to best optimize your images. The key is recognizing the problem and
knowing how to use your controls to improve the situation. Remember only change 1 setting!
To be safe, change them to the ‘middle’ option

Problem: Entire image appears too bright.

Current control settings:

Output Power 50%
TGC normal curve
GAIN 100%
Frequency 4MHz

Goal: darken the image (decrease the echoes)

Solution: Decrease the GAIN to 50%

Problem : High contrast image

Current control settings:

GAIN 50%
Focus position LOW
Dyn Range 40dB
Output Power 60%

Goal: Normal appearing liver texture

Solution: Softer grey-scale by increasing DYNAMIC RANGE to 60dB

Problem : Uneven brightness level

Current control settings:

Dyn Range 70dB
Depth 14cm
Focal number 1
TGC last 3 knobs to left (off)

Goal: Homogeneous texture

Solution: Adjust TGC to be even brightness

Problem : Poor lateral resolution

Gain 50%
Focal number 2
Focal position High
Frequency 10MHz

Goal: Improved resolution

Solution: Lower the focal position to low or middle

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Tissue Harmonic Imaging
Signal processing technique. Only changes how the machine will “listen” to the echoes.
What is a HARMONIC?
Basically, it is a multiple of the fundamental frequency (operating freq of transducer)
When echo is created, it vibrates at different frequencies in multiples of the original freq
Example: Transmitting at 4 MHz, results in echo freq of 4 MHz, 8 MHz, 12 MHz, and so on... 4 MHz would
be the 1st harmonic, 8 MHz would be the 2nd harmonic, etc.

Harmonic Imaging uses the 2nd harmonic frequency for signal processing

By processing the 2nd harmonic, it allows the machine to be “picky” with the echoes it
processes. For 2 reasons
1. Only real re ectors vibrate at harmonics. Noise is easily ignored.
2. Most harmonics are produced in the center of the beam, where non-linear sound
propagation occurs

Non-linear Sound Propagation

As an US pulse travels, it changes shape or distorts. Remember sound is a wave of high

(peaks) and low (troughs) pressures. High pressure travels faster than low pressure.
Pulse distortion occurs at the center of the beam where the signals are the
strongest (smaller beam interrogation) > improved lateral resolution
All weaker signals are ltered. These new peaks are the basis for the processed
image. Only the distorted harmonic signals remain.

Filtering techniques must be used to get rid of the fundamental frequencies. In

other words, all echoes received at operating frequency are thrown out

Pulse Inversion An inverted fundamental frequency is simultaneously applied to incoming

frequencies. Any matching frequency would be out-of-phase and canceled out. This is
called destructive interference
Interference principle
Constructive:
When the wave is in-phase, the peaks and troughs (compressions and rarefactions) are in line with each
other. The 2 waves combine to form a new wave with higher intensity. Resulting wave is BIGGER
Destructive:
When the cycles are out of phase, the peaks line up with the troughs. They destructively cancel each other
out (when perfectly out of phase)

Pulse Encoding Codes or marks the fundamental frequency. Anything coded will be
ltered, anything uncoded will be processed
CODED EXCITATION (improves the signal to noise ratio)
RESULTS : less artifacts, less noise, crisper images,
improved lateral resolution

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Pulse-echo Imaging Artifacts
An artifact is anything that does not match with the actual tissue being scanned. Could be
something that’s not real, missing objects, or in the wrong location.
What you need to do …. IDENTIFY, know the CAUSE, and HOW TO FIX it if possible

Reverberation
Multiple false echoes at regular intervals deep to a highly
re ecting objects.
Cause = 2 interfaces with a high impedance mismatch.
Beam gets ‘trapped’ between the two causing several
false re ections.
To reduce reverb: change scanning angle or transducer

• RING DOWN and COMET TAIL are forms of reverb

Ring down Comet tail

Several false echoes that just Multiple false echoes that
keep “ringing” down screen. gradually fizzle out.
Unable to count them Caused by small highly
Caused by larger strong reflecting objects such as
reflectors such as by the microcalcs and tiny air
diaphragm or bowel gas bubbles

Posterior Shadowing
Severe attenuation of beam. Dark band posterior to highly re ecting
object.
Large impedance mismatch = large re ection = little transmission.
Example: stones, ribs, bowel gas. Calci ed material gives a clean
shadow. Bowel gas gives a dirty shadow which appear hazy
Shadowing is a helpful tool since it tells us when we have a structure
that is calci ed.
To enhance the shadowing = Increasing frequency increases shadowing because it
increases attenuation.
Spatial compounding removes/reduces

Posterior Enhancement
Opposite to shadowing. Caused by lack of attenuation and produces
brighter echoes posterior to uid lled object. The machine assumes
attenuation is the same in all tissues. The echoes posterior to uid-
lled structure appear to have greater intensity. Bene cial for
diagnosis to differentiate cyst vs solid.

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Edge shadowing
Dropout or shadowing at the lateral edges of a round structure.
Caused by refraction. Curved surface at edge (oblique incidence)
and different prop speed
NOT helpful artifact. Drop out limits imaging of borders
How to x: change angle, spatial compounding

Double Image
Produces 2 of same object side by side. Caused by refraction usually
through rectus abdominus muscles in transverse plane. Single structure
is evaluated by 2 separate refracted beams. 2 separate sets of echoes
returned to machine and displayed as 2. Most commonly seen ML TRV
aorta. Aorta appears to be duplicated, 2 side by side.
How to x: move the probe

Beam Width Artifact

Cause: Loss of lateral resolution along the beam width. Echoes in a
sense ‘overlap’ or as seen as horizontal echoes instead of dots.
Lateral splaying of echoes may be noted. Often seen in the edges of
an echo free area
How to Fix : Improve lateral resolution: Increase line density,
decrease sector angle, check focal position, Harmonics ON

Slice Thickness Artifact

Beam’s elevation dimension or slice thickness causes echoes to blend into smaller
anechoic structures. Will show as low level echoes across the screen seen within
normally echo free structure or echoes lling a small cystic structure. Easily seen
when gains are too high
How to x: lower gain, adjust TGC, Harmonics

Mirror Image
Produces a mirror or copy of the real echoes posterior or deep to a
curved specular re ector.
Commonly seen with the liver (diaphragm = round specular re ector)

Part of beam is re ected perpendicularly at the interface, but not back

towards the transducer. It is re ected again traveling along same path.
Machine assumes all echoes come from straight beam. Re ected echoes are
displayed in a straight line as if originating from main beam.
How to x: Change scanning angle

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Side Lobe/Grating lobe Artifact
Side lobes are small bits of sound energy that escape from the transducer face.
Grating lobes are also escaping energy but they come from the beam itself. Each
lobe is like a tiny US beam and has the same characteristics as the main beam.
And can generate echoes just like the main beam. When they produce echoes,
machine does not know they come from a side lobe and assumes all echoes come
from main beam. Machine plots info according to depth along the main beam ∴
echoes will be misplaced on display.

Commonly seen as echoes/septation in cystic structures.

How to x: Change angle of insonation. Spatial compounding,
Harmonics
Apodization is the technique used to reduce side lobes by varying the
voltages across the elements

Propagation Speed Errors

Echoes appearing at incorrect depths because the medium’s propagation speeds is not
1540m/s. The range equation will not be calculated accurately = wrong depth location

Range Ambiguity Artifacts

Echoes placed at incorrect locations due to PRF being too high

Equipment Generated
Improper use of control settings such as gain/TGC
Overall gain too high results in amplifying noise and increase in
artifact echoes.
TGC inappropriately set leads to vertical non-uniformity of echoes.
CHECK settings!

Why do we care?
They can tell us a lot about what we are looking at. Posterior shadowing and enhancement are
diagnostic tools we use to confirm pathology. Know how use them to your benefit and you will
improve the sensitivity of your exams
The others we need to be aware of to avoid pitfalls of misdiagnosis. For example, if you do not know
about side lobes, you could image a cyst with an appearance of a septation instead of just a simple
cyst. Know how to identify and avoid them

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Doppler Instrumentation and Hemodynamics (31%)

The DOPPLER EFFECT

When there is a difference in motion between the sound source and the re ector, the
echoes come back at a slightly different frequency than what was sent out.
If moving TOWARDS the sound source = Received frequency will be HIGHER
If moving AWAY from sound source = Received Frequency will be LOWER

The change in frequencies is called the Frequency Shift or Doppler Shift.

A shift is a slight change, the difference between the received and
transmitted frequencies.
If the received freq is greater than the transmitted, it’s a positive shift.
If the received freq is less than the transmitted, it’s a negative shift

• Based on +/- and magnitudes we can determine:

Presence of ow, direction, and velocity
Presence: If there is a shift, there is ow
Direction: If it’s + or -, we will know if it’s moving away or towards us
Velocity: The magnitude of shift helps to determine velocity

Critical thinking…
Two doppler shifts are received. Vessel A is +3kHz and vessel B is -4kHz. Which vessel has the
higher velocity? Hint: what does the + or - tell us about the signal?

THE DOPPLER EQUATION

Doppler shift = 2 x Freq x V x cos∢

c

3 things will affect the Doppler shift:

Velocity Directly related. Inc velocity = inc shift / Slow velocity = small shift

Frequency Directly related. Inc freq = inc shift / Dec freq = dec shift

Angle Inversely related. 0 degrees is the greatest shift. 90 degrees = NO shift

Increasing doppler angle = closer to 90° = decreasing shift
Decreasing doppler angle = closer to 0° (same as 180°) = increasing shift

Know these relationships!

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Color Doppler Imaging

Doppler shift info colorized and superimposed or ‘pasted’ onto B-Mode image (duplex).
The color box is made up hundreds of scan lines. Each scan line is divided into sample
volumes. In order to be sensitive to moving blood, multiple pulses are needed.
PACKET SIZE or ENSEMBLE LENGTH = number of pulses per scan line (8-10 typical)
Increasing packet size will enhance quality and sensitivity but reduces frame rate.

Doppler shifts are received from sample volumes.

PHASE QUADRATURE DETECTION determines direction by detecting positive or
negative.
AUTOCORRELATION assigns a color for direction (ie- red for positive, blue for negative)
depending on color map chosen. Then assigns a shade or hue of that color to represent
avg velocity.

Our color scale display shows us what color is assigned for positive and
for negative. The color on top is always positive.
Scale also represents our PRF (displayed doppler shift freq) and the range
it’s able to detect (maximum velocity)

The scale should be set to the type of ow you are evaluating in order to
be displayed accurately
Slow ow = Low scale Fast ow = High scale

This images shows well how the difference in brightness and color are
affected by angle. Closer to parallel = higher doppler shift and therefore,
brighter color. Perpendicular (as shown by arrow) = NO doppler shift and
so black. Any vessel that loops or curves will show both red and blue as
part of the ow moves towards the transducer and then away as it loops
around.

How to correctly use Color Doppler

Steer the box in the direction of the vessel angle. Color box angle should be steered so
that the scan lines are closer to parallel to the ow. The closer it is to perpendicular means
lower doppler shift or no shift. The size of the box should just cover area of interest. Adjust
the scale to t the type of ow you are evaluating. Adjust color gain so color lls in vessel
but does not ‘bleed’ out of the vessel walls.

What is the direction of ow of the vessel in red?

First, notice the scale. What is red? Negative or positive? Away or
towards?
It is negative, so away. Box is steered to left, so ow is going away
from us (downhill) to the LEFT. The negative color is always going
towards the side the box is steered. The positive color is the
opposite.

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Pulsed Doppler

Applies same principles as color except now evaluate ow over one small area called our
sample volume or range gating. PW pulses have more cycles per pulse than B-Mode
imaging. Normally 6-10 cycles. Triplex when using all 3 modes
Bene ts: We decide position (where to sample) and size (how much to sample).
Information will be speci c and velocities can be measured

Processing of doppler shift into spectral waveform:

SPECTRAL ANALYSIS which breaks down the signal into separate components
according to velocity(magnitude of shift) and time(location).
Wall lters and High Pass lters are used to cut out low frequency noise/clutter.
Removes LOW FREQUENCY/HIGH AMPLITUDE. Reduces the display of low
frequency shifts whether it is real or not. Increasing the lter will get rid of more. If
the lter is too high, it will get rid of low velocity ow that is real.
Imagine the ow you are looking at produces a low frequency shift of 300 Hz
and the Wall Filter is set at 350 Hz. It will erase all information 350 and lower
including the real ow. Fix? Decrease the wall lter

Fast Fourier Transform displays the processed data as velocity vs time at a rate of
100-200 lines of data/second.

How to correctly use PW doppler

Sample at center of ow/vessel with sample angle steered in
direction of vessel and parallel to vessel walls. Since most vessels
run perpendicular to transducer, ideal angles are 45-60 degrees. If
the angle is not estimated correctly, velocity measurement will be
inaccurate. Sample gate should be approximately 1/3 the size of
the vessel

Bene ts Limitations

More speci c evaluation of sampling Subject to aliasing

Detailed velocity info Angle dependent
Calculations of velocity and other measurements Only samples where tech places gate

Basic measurements
Peak Systolic Velocity (PSV) and End Diastolic
Velocity (EDV) can be measured as shown in the
waveform

Using these measurements, Resistance Index (RI) and

Pulsatility Index (PI) can also be calculated

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NYQUIST LIMIT = 1/2 PRF

ALIASING occurs when the doppler shift EXCEEDS the Nyquist Limit.

When the frequency shift is greater than 1/2 the PRF, aliasing will occur.

The aliased color pattern is mosaic and The aliased spectral waveform appears to wrap
appears to be turbulent. The color over ows around the baseline. The peaks are cut off and
into the other color on the scale. Reds turn to appear on the other side
orange to yellow to white to light blue

How to eliminate aliasing

The problem simply is that the shift is to big for the scale. So increase the scale (or PRF)
If you can increase the scale, the shift will no longer exceed it.
With spectral waveform, you can also lower the baseline to help Eliminating aliasing
‘unwrap’ the waveform
Increase scale/PRF
What if you cannot do either?
Lower baseline
The other option you have is the decrease the shift. The Doppler
equation. Frequency and angle affect the doppler shift (pg 27) Decrease frequency
Decrease frequency will decrease the shift. Increase Doppler angle
Increasing doppler angle will decrease the shift

Q: What would be the effect to aliasing if the Doppler angle was reduced or frequency was increased?
A:There would be more aliasing. Decreasing angle or increasing freq = increased doppler shift

Sensitivity to SLOW ow
Now we have the opposite problem. Low velocity ow will produce a small doppler shift.
The opposite to aliasing.
Simply the problem is the shift is too small to see.
• Decrease the scale so the machine looks for lower velocity ow
• Decrease Wall lter to allow the display of low frequency shifts
• Increase the shift by increasing frequency
• Decreasing doppler angle by steering color box or rocking probe
• Increase color gain to strengthen the returning Doppler shift
• Persistence: Increasing will accumulate multiple color frames
• Increase packet size

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Console Settings and Image Optimization
Color and Doppler Images

The key to optimizing your images is recognizing the problem and knowing how to use
your controls to improve the situation

Problem: Color aliasing

Current control settings:
Color Gain 50%
Scale/PRF 30/-30
Color box angle LEFT
Goal: Accurately display the normal color ow
Solution: Increase the SCALE

Problem : Aliasing of spectral waveform

Current control settings:
Doppler gain 50%
Scale/PRF 60/-60
Baseline Center
Doppler angle 60 degrees
Goal: Eliminate artifact, visualize entire
waveform
Solution: Adjust baseline to LOW

Problem : Disappearance of diastolic ow

Current control settings:
Baseline Low
Scale 140/-20
Doppler gain 50%
Wall Filter 750 Hz
Goal: Visualize entire waveform
Solution: Decrease the wall lter to 250Hz

Problem : Spectral box is lled with echoes

Current control settings:
Doppler gain 80%
Wall Filter 250 Hz
Frequency 9 MHz
Sample size 2mm
Goal: Accurately display waveform
Solution: Decrease doppler gain to 50%

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Additional Doppler Modes

Power Doppler

AKA energy doppler, amplitude doppler

Only one color, usually yellow or orange.

** Maps magnitude/power/amplitude of doppler signal (not
velocities) Only detects and displays the presence of ow. NO
direction or velocity info. NO aliasing
Bene t: Very sensitive to slow ow

Continuous Wave Doppler (non-imaging)

Requires 2 separate crystals side by side: 1 transmitting & 1 receiving

NO PULSES = NO PRF = No Nyquist Limit ∴ no limit of max velocities ∴ no aliasing

Only used as ow detector or to measure severely elevated velocities.

Range ambiguous: unable to determine depth or location. Cannot choose a location. Will
sample ALL vessels in its path.

Doppler Artifacts

Aliasing of color and PW

Problem: Color appears to be turbulent mimicking disease. PW waveforms are cut off not
allowing the peak velocities to be measured.
Cause: Doppler shift exceeds Nyquist limit or scale
Solution: Increase scale/PRF, adjust baseline, decrease frequency, increase angle

Doppler Mirror aka Ghosting

Problem: Spectral mirror or crosstalk produces exact copy of waveform
appears below the baseline. Flow appears reversed. Color mirror will
show color copy below real ow.
Cause: When gain is too high, presence strongly re ecting objects, or
angle is close to 90
Solution: Decrease doppler gain or decrease angle

Flash
Cause: Large movements or respirations, cause ash of color to ll box. Sometimes occurs
when settings are too sensitive
Solution: Reduce motion if possible. Reduce gain, increase scale

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Hemodynamics

The study of blood moving through the circulatory system

Blood ow depends on 2 main things: Flow rate = pressure gradient

Pressure gradient and Resistance resistance

Greater pressure gradient “push” = more ow (directly related)

Increased resistance = less ow (inversely related)

Pressure gradient The driving force behind ow

Pressure gradient = difference in pressure from high to low
Greater the gradient = =greater amount of ow

Arterial ow is pulsatile because it is driven by the pressure

gradient from cardiac cycle.
Systole LV contracts (hi pressure) creating pressure energy that pushes blood into aorta
(low pressure)
Diastole Heart relaxes. Blood continues to ow through arterial tree because it is already
in motion (kinetic energy). How much ow will continue during diastole will depend on
resistance

Venous ow is phasic because it is moved by respiration. This means that ow comes and
goes depending on the phases of respiration.
Inhalation increases abdominal pressure and lowers chest pressure. Hi abdominal pressure
stops legs from owing. Low chest pressure allows arms to ow
Exhalation reduces abdominal pressure allowing lower extremities to ow up and
increases thoracic pressure so arm ow stops
Valsalva maneuver stops ALL venous ow because it increases chest and abd pressures

Hydrostatic (gravitational) energy: weight of column of blood (pull of gravity)

Supine: all same level as heart = 0mmHg at ankle
Standing: increases to 100mmHg at ankle
Hand raised above head: negative gravity = -50mmHg

Resistance
Increased resistance will decrease ow
Resistance is determined by
Vessel size length and diameter/radius
Thickness of blood (viscosity)
Outside forces upon vessel (elasticity of walls)

Biggest effects to resistance occur when there is a change of vessel diameter or radius

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Poiseuille’s Law = relationship of resistance, pressure gradient and volume ow ( ow rate)

Q = volume ow
ΔP = pressure gradient Increase pressure gradient = Increase volume ow
r = radius
ƞ = viscosity Increase resistance = Decrease volume ow
l = length

Decreasing diameter would increase resistance and decrease ow

Flow volume directly proportional to diameter. Notice how radius is to the 4th power.
That means small changes in radius result in big changes to ow.
Decreased radius = increased resistance = decreased volume
Flow is inversely related to length and viscosity

Resistance and US

Resistance is determined by where the ow is traveling to. The body regulates ow by

changing the resistance of the arterioles. If an organ needs constant forward ow, it will
have a vaso-dilated vascular bed. That means the arterioles are bigger. Bigger means lower
resistance. If a body part does not require constant perfusion, then its vascular bed will be
vaso-constricted. That means smaller and smaller means higher resistance.
We can tell resistance by how much diastolic ow there is.
Hi resistance = little or no diastolic ow. Possibly even ow reversal
Lo resistance = more diastolic ow. Constant forward ow

Examples:
ICA feeds the brain. Brain needs constant ow. It’s arterioles are dilated
(bigger) to reduce resistance. Notice waveform from the ICA. Lots of
diastolic forward ow= Low resistance

ECA feeds the face and neck. Does not require constant ow. It has a
constricted (smaller) vascular bed. Waveform has very little if any
diastolic ow = High resistance

In the case of obstruction

Arterial ow volume comes from cardiac output (how much heart pumps) so it cannot
change. We can’t tell the blood to slow down or stop when we have obstruction

This is described by the Law of Conservation of Mass

V=Q
A When vessel size decreases and volume is constant = Velocity must increase

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Bernoulli Effect describes the relationship of pressure and velocity at the location of a
change in vessel radius or diameter. Pressure and velocity are inversely related.
Hi Velocity = Low Pressure
Decrease velocity = Pressure increases
Example:When there is a decrease in radius (stenosis), the velocity increases and so
pressure (at the stenosis) decreases

Types of blood ow

Laminar
Normal ow that moves in concentric streamlines or layers. Organized. We can see
laminar ow by the quality of the spectral waveform.

The ow in this waveform is laminar because it has a spectral window.

The PW is sampling one, neat layer which moves at its own speed. So
the waveform displays a neat, organized ow pattern

Parabolic: most common type of ow. Highest velocities found

in the center of vessel and lowest next to wall. Parabolic
shaped ow

Plug: Found at origin of vessels. All layers move at the same

velocity

Turbulent
Abnormal, disorganized ow. Flow patterns become disturbed and form
eddies or swirling patterns. Occurs when we have a sudden change in
resistance and elevated velocities. Often seen distal to stenosis or tortuous
vessels. Loss of spectral window

Reynold’s #
Predicts when ow becomes disorganized or turbulent

CRITICAL VALUE = >2000

The 2 main factors are radius and velocity.

Both are directly related to Reynold’s#

r = radius The larger the vessel and higher the velocity will
V= velocity increase the Reynold’s # and more likely there will be
p = blood density
turbulent ow… “post-stenotic” turbulence
n = blood viscosity

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Ultrasound and Hemodynamics

In cases of stenosis, increased velocities will appear as aliasing since they will exceed
the PRF settings for the normal vessel.

In color, we will see aliasing (mosaic) at the location of stenosis and post-
stenotic turbulence. In this case, aliasing can be used diagnostically to
locate turbulent patterns.

In PW spectral analysis, we will nd elevated velocities. (Now is the time

to increase PRF in order to accurately display and measure peak systolic
velocities.)

Since all our layers are squeezed into reduced space, sample volume will pick up multiple
velocities at once. The spectral waveform will lose its clean spectral window and will ll
in with echoes. It broadens. Notice the difference between laminar and turbulent ow

Spectral broadening = turbulent ow Spectral window = laminar ow

Warning Your settings can either hide or create disease

Color Scale
In a normal vesseI, if the scale is too low, it will appear as aliased. Aliasing appears to be
turbulent ow. Increase the scale to demonstrate normal ow in a normal vessel.
When there is a stenosis, you want to show the turbulent ow. In this case, do not increase
the scale so much that it appears normal.

Color gain
Gain too high will make color ‘bleed’ out of vessel and can
underestimate disease.
Gain too low makes the vessel not lled in as if there is disease

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Doppler sample gate
The PW gate should be kept at approximately 1/3 the vessel size. If the gate is too large for
the vessel, the waveform will have spectral broadening even if the ow is really laminar.
This will happens because a large gate will sample all of the shifts that occur in the vessel.
It will display all of these shifts ‘ lling’ in the waveform.

In this example, the gate is too large and the doppler gain is too
high
Waveform appears to have spectral broadening. Doppler gate
should be made smaller and doppler gain should be decreased

Stenosis pro le

How stenosis affects blood ow. You can apply Pouseuille’s Law, Bernoulli Effect, and
Reynold’s number to understand the hemodynamics of a stenosis

A.Proximal to stenosis. Decrease in diameter upstream = increase in

resistance. Hi resistance waveform (less diastolic) is noted

B. At the stenosis. Elevated PSV and EDV through the narrowed section.
Velocity must increase when area decreases to maintain volume ow.
Bernoulli effect says that lowest pressure is found here

C.Distal to stenosis. Turbulent ow patterns. According to Reynold’s

number, the larger radius with the elevated velocities will increase the
likelihood of turbulent ow patterns. We call this region ‘post-stenotic
turbulence’. Lo resistance waveforms since vessel widened. Flow may
also be dampened distal to severe disease

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Clinical Safety 10%
ALARA As Low As Reasonably Achievable
We keep power settings and acoustic exposure to a minimum to reduce risk of bioeffects

Possible Bioeffect Indices : measures risk or likelihood. NOT if it’s actually happening

Mechanical AKA cavitation Thermal

Change in pressure due to sound wave Tissue heating when sound is absorbed. Absorption
microbubbles form, grow, and can collapse converts pressure into heat causing rise in tissue
causing damage to cells. During rarefaction: temperatures
expansion phase where bubbles are likely to form
Thermal Index (TI)
Mechanical Index (MI) Risk of tissue heating indicated by TI
Measure of likelihood of cavitation TI of 1 = rise of 1℃

Maximum allowable intensities Unfocused 100 mWatts/cm²

Focused 1 Watt/cm²

Intensities are measured based on machine settings

Spatial intensities. Intensity is power/area so intensity will vary
depending on size of beam and location within the beam.
Spatial Peak SP Center of the beam
Spatial Average SA Average intensities across the beam

Temporal intensities. We use pulsed US, so intensity changes with

time.
Temporal Peak TP Highest intensity found at peak of the pulse
Pulse Average PA Average intensity over the pulse itself
Temporal Avg TA Average intensity over the whole time
(including listening time)
SPTP
Combined intensity measurements SATP
Highest to Lowest SPPA

To calculate MI and TI, machine uses these intensities based on current SAPA
power and control settings SPTA
SATA
SPTA is used to calculate TI SPPA is used to calculate MI

What control settings that you control would also change the risk of bioeffects?
Think about if the following settings would change MI or TI and how

Output power Depth Multiple focal zones Gain Doppler modes

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Safe environment for you and patient

Preventative maintenance is part of clinical safety. Like routine check ups and cleaning on
car (oil change, check tires, etc) are important for safe driving.
Preventive maintenance includes keeping machine and XDCR’s clean, cleaning air lters,
keeping XDCR cords from being tangled or run over. Check control panel and inspect
probes for wear.

Protect patient
Cleaning and disinfecting probes with approved disinfectants. Probes cannot be sterilized
since that requires extreme heat and will damage crystal. Disinfect with solution
containing Gluteraldehyde (ex- Cidex or T-spray). When contact with bodily uids: 1st
rinsed, then soaked 15min. NO bleach, needs to be approved disinfectant or hydrogen
peroxide
Universal precautions include hand washing between patients, changing gloves. Masks
and gowns when necessary

“Time-Out” take time to make sure you have the correct patient and correct exam before
beginning exam

Sterile Technique
Touch only the outside wrapper, not the sterile supplies with ungloved hands.
Do not to reach over the sterile supplies when doing the procedure
Unfold the sterile paper wrapper of the kit or tray. Always open the ap away from you. If
you need to add sterile dressings or other items to your tray, open the package. Holding
the outside of package, drop the item so it lands near the center of your tray. Throw the
outer wrapper away. When something non-sterile comes in contact with sterile tray, all
becomes non-sterile.

Protect yourself

Use ergonomic techniques while scanning to prevent injury and muscle strain.
Basic rules of ergonomics:

Shoulder abduction <30 degrees Adjust the height of your exam table and your
chair. Avoid twisting or bending
Wrist 20 degrees most extended angle and
<40 deg for max exion Get closer to your patient

Try to use a palmar grip for the majority of each Position monitor in front of you at eye level
exam. Allows for neutral wrist position

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Quality Assurance
QA is medically and legally necessary, must be done periodically and routinely.
GOAL: to ensure all equipment meets and performs up to standard, maintaining optimal
image quality.

Performance Testing

AIUM’s 100mm test object

Fluid- lled tank with same propagation speed as soft tissue but without attenuation
(doesn’t look like tissue). Stainless steel pins strategically placed to produce re ections. To
test distance and accuracy of system: caliper accuracy, spatial resolution, dead zone.
Cannot test grey scale properties

Tissue Equivalent Phantom (TEP)

Similar properties as soft tissue including propagation speed of
1540m/s and attenuation rate of 1/2dB/cm/MHz. Looks the same as
soft tissue. Contains nylon wires and objects to mimic simple cysts
and solid masses. Ability to evaluate grey-scale, focal zones, spatial
resolution, caliper accuracy, depth calibration, dead zone,
elevational resolution, sensitivity

A Dead Zone The dead zone is the space close to XDCR face
that cannot detect echoes. The rst pin detected in section A is
the depth of the dead zone

B Spatial Resolution Made up of pins closely spaced

horizontally and vertically.
Vertical pins = axial resolution
Horizontal pins = lateral resolution

C Horizontal Caliper Accuracy The TEP doesn’t lie. So if

calipers on image give a different measurement, they need to be
calibrated

D Slice Thickness and Elevational Resolution Section of cystic

spaces of differing sizes and different depths. The cysts that appear clear and echo-free tell
us the elevational resolution thickness

E Grey Scale Accurate and uniform presentation of cystic to solid looking masses.

Depth calibration (or depth measurement accuracy) evaluated by measuring objects along
vertical axis at 1cm intervals. If off, can be recalibrated

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Doppler Phantom
Device within TE phantom that propels uid in a tube used to evaluate doppler
instrumentation accuracy such as velocity measurements, caliper accuracy, scale, etc

No test object can test for temporal resolution (frame rate)

Sensitivity
Ability of machine to detect and display low level echoes. No variance (change over time)

Minimum sensitivity The weakest echo that can be found in far eld. TGC are set
at and gain is increased until deeper rods appear
Normal sensitivity The setting that all pins are displayed. Should not change over
time
Maximum sensitivity Power and gain is set to max levels. Max visualized depth can
be determined

Malfunctions
Malfunctions may be found during QA or PM’s or during day to
day imaging as an artifact.

All dysfunctional equipment should be recorded and repaired as

soon as possible.

Black shadow from the transducer face indicates broken or cracked

crystal

Gold Standard

Gold standard testing is basically statistics, checking the accuracy of the non-invasive test (like
ultrasound) against whats considered the “truth” or gold standard which would be the test that is
more accurate and usually the more invasive exam.

Sensitivity is how good the test is at detecting disease. Ex - In 10 patients with gallstones, only 9
were detected with US. The sensitivity would be 9/10
Speci city is how good the test is at detecting normal. Ex - In 20 normal patients, 18 accurately
were found to be normal by the ultrasound. The speci city would be 18/20

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New Technologies

Elastography
Maps the elasticity or stiffness of tissue. Helps to distinguish
between benign or malignant tumors and other conditions
that affect tissue density. Commonly used in breast and
abdominal imaging

3D and 4D imaging
Volumetric data acquisition, volume data analysis, and volume data display. The 3rd
dimension is the coronal plane. 4D is the addition of time (real time 3D)
Requires a volume of tissue to be scanned and reconstructed

Electronic 3D probe has over 2,000 elements. Collects volume data from pyramid
shaped US beam and processes simultaneously. Able to do 4D since it all
simultaneous. Display rate of > 20 vol/s Measurement accuracy due to automated
sweep

Traditional probes with 3D capabilities require a sweep to acquire the 3rd dimension.
These are not as accurate as electronic 3D/4D probes. Tech dependent

Display modes
Multi-planar- 3 orthogonal planes (SAG, TRV, and Coronal) and/or volume
rendering can be displayed. Able to sweep through any of 3 planes
simultaneously or rotate volume. Or display each separately.

Volume rendering will show the surface of the volume and constructs and
image with color, texture, shadows. Able to produce “photographs” of baby
in the womb. Can be done off-line = post-processing

All machines controls can be used to optimize 3D image same as 2D (depth, gain, TGC,
FR, focal point, etc.)

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Contrast Agents
Microbubbles trapped in a shell that can be injected intravenously. The tiny bubbles are
highly re ective and will appear very bright on the image. The purpose is to ‘light up’
blood chambers or vessels. Not like contrast of MRI or CT. It is only bubbles in a saline
solution. No dye, safe for all patients
Main use now is for Cardiac to see LV function.

Must use low MI settings. Higher output and increased cavitation causing bubble
destruction. Harmonics may still be used to increase echo intensity, Doppler signals also
may be improved due to increased amplitude echoes.

Tissue doppler
Used in echo for cardiac function by measuring the velocity
of the moving heart muscle during cardiac contraction.
AKA myocardial motion.
Uses doppler just like for blood ow, except detecting the
movement of the muscle. Wall lter or high pass lter is
turned off as we want to see the high amp/low freq shifts

Ultrasound hybrid imaging

aka fusion imaging. A combo of ultrasound with either CT or MRI. One probe that will
scan with ultrasound and a CT image at the same time. Primarily used for diagnosis,
staging of tumors and cancers. Also during ablation procedures. Combining both
modalities allows for more accurate reading.
Contraindications = pt who cannot have CT or MRI due to allergies or metal within body.

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