ULTRASOUND PHYSICS

AND TECHNOLOGY
For Elsevier

Commissioning Editor: Claire Wilson

Development Editor: Catherine Jackson
Project Manager: Jane Dingwall
Designer: Kirsteen Wright
Illustration Manager: Gillian Richards
Illustrator: David Gardner
ULTRASOUND PHYSICS AND

TECHNOLOGY
How, Why and When

Vivien Gibbs DCR, DMU, MA, MBA

Senior Lecturer, Faculty of Health and Life Sciences,
University of the West of England, Bristol, UK

David Cole TDCR, DMU, BSc, MSc

Postgraduate Medical Ultrasound Programme Director,
Division of Radiography, Faculty of Health,
University of Central England, Birmingham, UK

Antonio Sassano BSc, MSc, AVT

Senior Lecturer, Faculty of Health and Life Sciences,
University of the West of England, Bristol, UK

Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  Toronto 2009
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 Contents
......................................................................................................................................

1 Introduction to diagnostic ultrasound 1

2 Principles and physics of ultrasound imaging – simple terminology definitions 7

3 The piezoelectric effect 13

4 Acoustic impedance 19

5 The ultrasound beam 23

6 Transducers 27

7 Resolution 39

8 Ultrasound interactions and attenuation 45

9 Artifacts 51

10 Instrumentation and controls 63

11 Physical principles of Doppler ultrasound 73

12 Ultrasound safety 91

13 Quality assurance and performance testing 101

14 New technology and recent advances in ultrasound imaging 111

15 Multiple choice questions 121

Answers to multiple choice questions 127

Index 133

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 Introduction to diagnostic
ultrasound
1
......................................................................................................................................

CONTENTS
The growth in the use of ultrasound as a diagnostic
imaging tool has been rapid. Until 30 years ago ultra-
sound examinations were rarely performed in the
Audible sound 1 hospital setting, but now this method of diagnosis
Ultrasound 2 is routine, and comprises over 25 per cent of diag-
nostic imaging examinations undertaken in the
investigation of disease. A number of factors have
contributed to this success, but chief among them is
the relative simplicity of the process involved in
obtaining diagnostic images.
A wide range of healthcare professionals now use
ultrasound as a diagnostic tool. However, any practi-
tioner using diagnostic ultrasound needs to have an
understanding of the fundamental principles under-
lying the physical production of sound waves and
echoes, in order to become fully competent in the
diagnosis of information produced by the technique.
This book seeks to provide the reader with the infor-
mation required to underpin the practice of sono-
graphy in a format that is straightforward and easily
accessible.

......................................................
AUDIBLE SOUND
Sound is a form of energy which causes a mechani-
cal disturbance in the form of vibration of molecules
within a medium. In order to be transmitted, sound
requires a medium containing molecules, and there-
fore cannot travel through a vacuum. The produc-
tion of sound requires a vibrating object, such as a
tuning fork, which when physically struck will
vibrate. It will then cause adjacent air molecules to
vibrate, and these in turn will cause their neighbor-
ing molecules to vibrate. This disturbance will
spread through the air as a longitudinal wave. This
means that the wave travels from the source of the
vibration, parallel to the direction in which the

1
1 Ultrasound physics and technology

particles vibrate. The phase of the wave when the

molecules are pushed together is called compression,
and when apart, rarefaction.

......................................................
ULTRASOUND
.
Ultrasound is the name given to high-frequency
sound waves, which are above the human hear-
ing range. Diagnostic ultrasound travels in a simi-
lar way to audible sound. It consists of minute
mechanical vibrations (pulses of ultrasound) which Fig. 1.2 · Echoes are returned when the sound wave
are transmitted into the body. As the ultrasound encounters an interface between two tissues of
differing density
wave propagates (travels) through the body, it
causes a local displacement of molecules within
the medium. Figure 1.1 shows the changes occurring
within a medium as the sound travels through it. However, since sound is not related to the electro-
During its journey, the sound wave will encoun- magnetic spectrum, there is no tissue ionization,
ter different types of tissue and, depending on the and the technique is therefore free from the
density of the tissue (how closely the molecules of hazards associated with X-ray imaging.
the material are packed together), so the speed at
which the sound travels will alter. This feature is The History of Ultrasound
known as the acoustic impedance of the material.
The denser the medium, the greater the acoustic By the early twentieth century, the existence of
impedance, and the faster the sound will travel. inaudible high-frequency sound waves had been
Therefore ultrasound will travel faster in bone than established, and in 1916 the first working ver-
in fat, for example. sion of a marine sonar (sound navigation and
The point at which the tissue type changes (the ranging) system was used during the First World
interface) is where there is a change in acoustic War to detect enemy submarines. From this, a
impedance (and a change in speed of travel of new technique was developed for industry using
the sound), and this will cause part of the pulse to high-frequency pulse-echo techniques which were
be reflected back in the form of an echo, with the applied to the detection of flaws in metallic
remainder traveling on through the body (see structures.
Fig. 1.2). The larger the difference in acoustic imped- Research progressed into using the technique
ance between two tissues, the more sound will be for biological therapeutic and diagnostic applica-
reflected back to the transducer and the less sound tions, but it was not until the early 1950s that
will carry on traveling through the tissue. These the first clinical images were published. Because
returning echoes are converted into a visual display air does not transmit ultrasound waves efficiently,
and used to form a sectional image. This sequence the air interface between the transducer and the
of events is known as the pulse-echo principle. patient’s skin was initially a problem. Early scan-
Diagnostic ultrasound is a form of radiation ning techniques required the patient to be
because it uses energy emitted from a source. immersed in a bath of water in order to provide
good transmission of sound waves into the body
(see Fig. 1.3).
However, as this was an inconvenient technique
. .. ... .. . . .. ... .. . . .. ... .. . for routine clinical use, the first contact compound
. .. ... .. . . .. ... .. . . .. ... .. . B-scanner (using olive oil as a lubricant) was
. .. ... .. . . .. ... .. . . .. ... .. . developed in the late 1950s (see Fig. 1.4). This
. .. ... .. . . .. ... .. . . .. ... .. . equipment used a single crystal, mounted on the
Fig. 1.1 · Areas of compression and rarefaction in a end of an articulating arm (see Fig 1.5), to produce
medium as the molecules are displaced static images. Each scan was time consuming to
2
 Introduction to diagnostic ultrasound

complete, as it required the operator to move the

crystal across the area of interest in a linear sweep,
in order to provide sufficient cross-sectional
information to make a diagnosis.
Early ultrasound equipment visual displays used
storage oscilloscopes which produced bi-stable
(black and white) images (see Fig. 1.6). It was only
in the 1970s that gray scale imaging was intro-
duced, enabling the display of a wide range of
echo amplitudes. More subtle variations in tissue
density were provided by these images, enabling
the diagnosis of a wider range of disease processes.
Real-time scanning systems were introduced
Fig. 1.3 · A patient being scanned in a waterbath in
1954 (Reproduced from Shirley et al 1978.) in the mid 1970s, which not only enabled the
visualization of moving structures, but also helped
to speed up the examination time. Dynamic sono-
graphic information was available for the first
time, greatly enhancing the use of ultrasound as
a diagnostic tool.
During these developments, research into the
application of Doppler techniques was ongoing
for many years, and the technique began to be
used routinely for the detection and measurement
of blood flow during the 1980s. Ongoing research
into this, together with the use of micro-bubbles
as a contrast medium, continues to expand the
diagnostic applications of sonography.

Safety of Ultrasound
The ultrasound beam is potentially hazardous
Fig. 1.4 · A contact compound B-scanning to the patient. As it travels through the body the
machine (Reproduced from Shirley et al 1978.)
beam interacts with tissue, and if exposure is

Fig. 1.5 · A single crystal transducer mounted on an Fig. 1.6 · A bi-stable image of a renal cyst (Reproduced
articulating arm (Reproduced from Shirley et al 1978.) from Shirley et al 1978.)
3
1 Ultrasound physics and technology

sustained and of sufficient intensity, it has the poten- will be assigned to an individual pixel according to
tial to cause a lasting biological effect. The implica- how large the returning echo is, and the digital
tions of many of the processes that occur are not number for each pixel determines the shade of
yet fully understood, however two of the effects that gray used to represent it on the display. Consider-
have been observed are caused by thermal and able processing and manipulation of this echo data
mechanical processes. The thermal effects arise has to occur before it can be meaningfully dis-
because some of the ultrasound energy is converted played. Processing takes place either before storage
into heat, causing an increase in tissue temperature. (pre-processing) or after (post-processing). Many
The mechanical processes are a result of the presence processing functions can be manipulated by the
of air in soft tissues (such as the lungs or intestines) operator (see Chapter 10 on Instrumentation and
which can cause damage to cells as the air bubbles controls) and have a considerable effect on the
expand under the influence of the ultrasound beam quality of the image. Incorrect use of these controls
(see Chapter 12 on Ultrasound safety). can lead to the production of artifacts and misinter-
The degree of damage caused by these effects pretation of the image (see Chapter 9 on Artifacts).
depends on a number of factors, including the
length of the scan, the type of tissue being scanned
The Image
and the power of the ultrasound beam. Anyone
performing an ultrasound scan therefore needs to After the returning echo signals have been elec-
be aware of the possible hazards involved, in order tronically processed and amplified they are dis-
to take the necessary precautions to limit possible played as shades of gray, ranging from black to
damage to the patient. white. Most systems have the capability to display
up to 64 shades of gray on a monitor. Stronger
reflectors will be displayed as white on an image,
Ultrasound Equipment
weaker echoes will be less bright, and areas with
The device which transmits the sound into the no echoes will be portrayed as black.
patient and detects the returning echoes is called All ultrasound images are composed of many
the transducer. The term transducer means a device lines of echo data, placed closely together so that
that converts one form of energy into another. The the image appears continuous. The area of the
primary component of the transducer is the piezo- patient displayed on any image is limited by
electric crystal which enables the conversion of elec- the section through which the beam will sweep.
trical pulses into mechanical energy (sound), and The width is determined by the type of the trans-
will also convert mechanical energy into electrical ducer, and the depth by the length of time for which
signals. Most ultrasound equipment now uses the echoes are recorded following transmission of a
pulsed sound, which means that a voltage is applied pulse. The depth is variable according to operator
to the crystal for a fraction of a second. This distorts requirements, but usually has a maximum of 25 cm.
the crystal and a pulse of ultrasound is therefore pro- The plane that an ultrasound image represents is
duced. The crystal will then relax while it is waiting the section through which the ultrasound beam
to receive a returning echo. Only 1 per cent of the sweeps, and this is determined by the position and
operating time is spent by the transducer transmit- orientation of the transducer. During scanning, the
ting sound, whereas 99 per cent of the time is spent operator is required to move the transducer in order
listening for echoes. to view images in at least two planes, and to use this
Echoes detected by the transducer give rise to very information to build up a mental three-dimensional
small voltage signals in the piezoelectric crystal. By image of the area being surveyed.
measuring the time it takes for an echo to arrive In order to understand the basic principles of diag-
back at the transducer, the depth of the echo can nostic ultrasound it is important to have a working
be calculated by the equipment. These signals are knowledge of the basic physics of sound, and the
then amplified, converted into a digital format way in which high-frequency sound interacts with
and stored as digital numbers in a computer mem- biological tissue. The following chapters will explore
ory known as a scan converter. Each digital number in more detail some of these principles.

4
 Introduction to diagnostic ultrasound

Reference Howry DH, Bliss WR 1952 Ultrasonic visualisation of soft

tissue structures of the body. Journal of Laboratory and Clinical
Shirley I, Blackwell R, Cusick G et al 1978 A user’s guide to Medicine 40:579.
diagnostic ultrasound. Pitman Medical, London.
Meire HB, Farrant P 1982 Basic clinical ultrasound. BIR Teaching
Series No 4.
Further reading
Brown TG 1960 Direct contact ultrasonic scanning techniques
for the visualisation of abdominal masses. In: Proceedings of
the 2nd International Conference on Medical Electronics. Illiffe
& Sons Ltd, London, p 358.

5
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 Principles and physics of
ultrasound imaging–
simple terminology definitions
2
......................................................................................................................................

Absorption: This is the major cause of attenuation.

Absorption occurs when ultrasound energy is lost
power and exposure time to a minimum while
acquiring the necessary clinical information.
to tissues by its conversion to heat. Higher fre-
Amplitude: The height of a wave. The amplitude
quency waves undergo greater absorption.
and intensity of sound represent the energy asso-
Acoustic impedance: A property of all substances ciated with the sound wave. The greater the ampli-
and is equal to the product of the tissue density tude or intensity, the more the energy, and the
and the speed of sound. Comparatively speaking, ‘louder’ the sound. Increasing the acoustic power
two substances with greater differences in acoustic will increase both the intensity and the amplitude
impedance produce stronger ‘echoes’ or reflected (see Fig. 2.1).
waves than two similar substances. Structures of
Anechoic: Areas on the image showing no internal
different acoustic impedance (for example, gall-
echoes, appearing dark or black on the image.
bladder and gallstone) are easier to distinguish
from one another than two structures of similar Artifacts: In the context of ultrasound, artifacts are
acoustic impedance (for example, liver and echo signals whose displayed position on the
kidney). image does not correspond to the actual position
of a reflector in the body, or whose displayed
Acoustic power: The rate of flow of energy through
brightness is not indicative of the reflecting or scat-
the cross-sectional area of the beam.
tering properties of the region from which the
Acoustic waves: These are the vibrations that occur echo originated. Artifacts are a result of the follow-
as a result of the rapid forward and reverse vibra- ing programmed machine assumptions:
tions of the transducer, and which result in a num- 1 The speed of sound propagation is the
ber of longitudinal waves being transmitted. The same in all tissue types
transducer causes molecules in the medium 2 The ultrasound beam travels in straight
through which it is passing to vibrate in a series lines
of rhythmic, mechanical compressions (high-pres- 3 The time taken after emission of a pulse
sure regions) and rarefactions (low-pressure for an echo to return to the transducer
regions). These vibrations are commonly known
as acoustic waves.
Acoustic window: An area of the patient that High pressure
Amplitude
enhances ultrasound transmission and provides
optimal scanning access to the area of interest.
To improve image quality, ultrasound transmis-
Low pressure
sion should be as uniform as possible and areas
which are likely to cause artifacts (such as ribs or
bowel gas) should be avoided.
Wavelength
ALARA: An acronym for ‘as low as reasonably
achievable’, referring to the principle of keeping Fig. 2.1 · Sound can be depicted as a sine wave

7
2 Ultrasound physics and technology

from an interface is directly related to the the operator’s manual. Some scanning machines
distance of the interface from the provide continuous assessment of the potential
transducer risk of bioeffects due to cavitation, by calculat-
4 Attenuation of sound in tissue is uniform ing the mechanical index (MI) for a given trans-
5 All echoes detected by the transducer have ducer in a particular mode during a scan. The MI
arisen from the central axis of the beam is inversely proportional to the square root of
6 An echo generated at an interface returns the frequency; thus, as frequency increases, MI
directly in a straight line to the transducer decreases.
without generating any secondary echoes
Contact coupling: This can be either gel or liquid.
7 The intensity or strength of the returning
Adequate coupling agent is needed to ensure that
echo is proportional to the density of the
there is no air between the transducer and the
reflector generating the echo.
skin.
Attenuation: The process that occurs as a sound
Coronal plane: Divides the body into anterior and
wave travels through a medium; it loses energy,
posterior sections, perpendicular to the sagittal.
and as a result, its intensity and amplitude decrease,
and it becomes attenuated. Attenuation is propor- Depth: The depth range or depth control varies the
tional to the frequency of the sound wave and depth of the patient which is displayed on the
the distance that the wave travels. The higher the image. The optimal depth is dependent upon
frequency and the further the wave travels, the beam penetration, which is determined by the
greater the attenuation. Attenuation results from transducer frequency.
three main effects: absorption, reflection, and
scattering. Diffuse reflectors: These are also known as scat-
terers, and reflect sound in all directions. The
Axial resolution: This refers to reflectors that lie brightness is not dependent on the angle of the
along the axis of the ultrasound beam. This resolu- incident beam.
tion is dependent upon the pulse length, which is
equal to the product of the number of cycles in a Doppler shift: This is the phenomenon that occurs
pulse and the wavelength. If two reflectors along when sound is reflected from a moving object
the axis of the ultrasound beam are separated by a and the frequency of the reflected sound changes.
distance longer than half the pulse length, they will The change in frequency is known as the Doppler
appear as two separate reflectors. If the distance shift, named after Christian Doppler, the Austrian
between the reflectors is less than the pulse length, physicist, who described it in 1842. Analysis
they will appear as one reflector. Since the wave- of the Doppler shift can be used to determine
length and frequency are inversely related, axial the speed and direction of blood as it courses
resolution is improved by increasing the frequency through the cardiovascular system. A positive
of the transducer. Thus, high-frequency transducers Doppler shift means that the received frequency
have better axial resolution. exceeds the transmitted frequency and that red
blood cells are approaching the transducer. A
Beam former: Provides pulse delay sequences to negative Doppler shift means that the received
individual elements (an element consists of a piezo- frequency is less than the transmitted frequency
electric crystal and its electrical connection) to and that the red blood cells are moving away
achieve focusing of the ultrasound beam. from the transducer.
Cavitation: The pressure oscillations produced by Dynamic range: This allows the range of echoes or
sound can create gas bubbles from the air dis- shades of gray displayed on the screen to be de-
solved in tissue fluids. If the oscillations are rapid creased. This will remove low-level echoes from the
and intense, they can cause the bubbles to display and result in an image with more contrast.
expand, contract, or collapse. The potential for
cavitation is related to the acoustic pressure ampli- Echo: A sound wave that is reflected from a tissue
tudes produced by the ultrasound system. These interface at 90 and is received by the ultrasound
amplitudes are reported by the manufacturer in transducer.
8
 Simple terminology definitions

Echogenic: This is an ambiguous term and should deliver more energy or power to the patient. A
be avoided, unless used as a comparative descrip- number of criteria are used to indicate the amount
tor, e.g. increased echogenicity (meaning increased of power or acoustical output of scanners. These
reflectivity). criteria are specific to the system and to the manu-
Electrical shock: A damaged transducer housing, or
facturer and can be found in the operator’s manual.
a break in the insulation of the transducer cable, Some equipment provides continuous assessment
can result in a significant electrical shock to the of the potential risk of bioeffects due to heating,
ultrasonographer or to the patient. This bioeffect by calculating the thermal index (TI) for a given
is easily prevented by regular equipment mainte- transducer in a particular mode during a scan. To
nance and frequent checks of the cable, trans- reduce bioeffects, the TI and exposure time should
ducer, and electrical connections. be minimized. Obviously, the higher the TI, the
lower the exposure time should be.
Focus: To improve the resolution at a given depth,
the transducer must be focused in order to narrow Hyperechoic: Areas on the image with more reflected
the beam width. This can be performed electroni- echoes (brighter) than surrounding tissue.
cally by varying the number of transmitting and
Hypoechoic: Areas on the image with fewer
receiving elements and by delaying the signal once
it is received from some of the elements. reflected echoes (darker) than surrounding tissue.

Frequency: The number of cycles of acoustic waves Image characteristics: Image characteristics are
per second. The unit of frequency is the hertz (Hz). determined by ‘reflectors’ and ‘scatterers’ of the
One cycle per second is equal to 1 Hz; 106 cycles/ ultrasound beam. The degree to which an area
second is equal to 1 megahertz (MHz). Audible reflects, transmits, and scatters the ultrasound
sound has a frequency between 20 and 20 000 Hz, beam determines how brightly it is portrayed on
whereas ultrasound has a frequency greater than the image.
20 000 Hz. Diagnostic ultrasound has a frequency Impedance matching layers: These layers are inter-
of 2–20 MHz. faced between the crystals and the patient to reduce
Gain: The degree of amplification of the returning the acoustical impedance mismatch between the
echo is called the gain. Echo or signal amplifica- patient and the transducer. A high acoustical
tion is necessary because the returning echoes are impedance mismatch between the patient and the
too weak to be displayed and visualized. Echoes transducer would create a strong reverberation
can be strengthened by increasing the intensity artifact.
of the transmitted signal (that is, increasing the
Intensity: Defined as the power per unit area and
power) or by increasing the amplification of the
expressed in milliwatts per square centimeter.
returning signal (that is, increasing the gain).
Mathematically, the gain is the ratio of the signal Isoechoic: Areas on the image showing a level of
amplitude input into the amplifier to the signal reflected echoes similar to that of surrounding
amplitude output from the amplifier. Gain is com- tissue.
monly expressed in decibels (dB). If the gain is
increased too much, then inherent noise within Lateral resolution: This refers to reflectors that lie
the system will also be amplified, leading to poor perpendicular to the axis of the ultrasound beam.
image quality. The resolution is related to the beam width; that
is, the wider the beam, the poorer the lateral reso-
Heat: Absorption represents the conversion of lution. An ultrasound beam is narrowest at its
ultrasound energy to heat. Heating is one of the focal length, and this is where the lateral resolu-
mechanisms for the production of biological effects tion will be optimum.
by ultrasound and is proportional to the power
applied to the beam or pulse and the duration of Overall gain control: This simple gain control
exposure. Imaging modes using more frequent increases amplification of echoes from all depths;
pulses (higher pulse repetition frequency (PRF)) it has an effect similar to increasing the power.
9
2 Ultrasound physics and technology

Piezoelectric effect: An effect exhibited by certain be reflected back to the transducer. The electrical
crystals with piezoelectric properties. The crystal signal that is generated from those waves is pro-
changes shape and vibrates when a voltage is portional to the strength of the returning wave.
applied to it. These are the primary components The strength of the returning wave is proportional
of ultrasound transducers. The most common type to the amount of difference in acoustic impedance
of piezoelectric material found in ultrasound between the two tissues at the interface. The ultra-
transducers is lead zirconate titanate (PZT). These sound image is formed only by those waves that
specialized crystals enable the transducer to con- are reflected back and received by the transducer.
vert electrical energy into acoustic energy during
transmission, and to reverse the process (that is, Pulse repetition frequency (PRF): The PRF controls
convert acoustical energy into electrical energy) the rate at which pulses of sound waves are pro-
during reception. If piezoelectric materials are duced and transmitted.
heated, they become depolarized and lose their Pulse transmitter: Provides electrical signals to
piezoelectric properties. Therefore, ultrasound excite the piezoelectric crystals. The pulsing signals
transducers should not be heat sterilized! In addition are applied at a rate known as the pulse repetition
they are sensitive to mechanical shock and should frequency (PRF). The PRF varies from 500–
not be dropped! 12 000/s with the operating mode and other set-
Power: Increasing the output power to the trans- tings on the machine. For example, real-time gray
ducer produces high-intensity ultrasound pulses. scale imaging requires a PRF of 2000–4000/s,
This increases the amplitude of the electrical signal whereas pulsed Doppler requires a PRF of 4000–
applied to the transducer, which has the effect of 12 000/s.
making returning echo signals from all reflectors Reflection: This occurs when two large structures of
appear brighter. The disadvantage of increasing significantly different acoustic impedance (such as
the power is that acoustic exposure of the patient an organ boundary) form an interface, the inter-
increases. face becomes a reflector, and some of the wave
Presets: After a transducer and a type of scan (that energy is reflected back to the transducer. The
is, abdominal, vascular, obstetric, etc.) are selected, energy remaining in the wave (not reflected, but
the system can be programmed to automatically transmitted beyond the interface) is decreased.
select certain controls, such as the power or gain Reflection occurs when a sound wave strikes an
controls. This can save time setting up the equip- object that is larger than the wavelength.
ment for each individual patient; however, there Refraction: When the beam encounters an interface
are often occasions when the preset is not ade- between two different tissues at an oblique angle,
quate and the operator therefore needs to have the beam will be deviated as it travels on through
an understanding of the controls in order to opti- the tissue. This is known as refraction. If the angle
mize the image quality. of incidence is 90 , no refraction will occur.
Propagation speed: The speed at which sound
Resolution: The ability of an ultrasound system to
moves through a medium, and is equal to the prod- distinguish two closely spaced reflectors as sepa-
uct of wavelength and frequency. Generally, the rate structures is known as resolution.
speed depends on tissue density and is lowest in
gases, higher in liquids, and highest in solids. The Sagittal (longitudinal) plane: Divides the body into
average speed of sound in soft tissue is 1540 m/s. right and left sections, parallel to the long axis.
Pulse-echo principle: This refers to the process Scattering: This occurs when an ultrasound wave
which occurs when ultrasound waves encounter strikes a boundary or interface between two small
an interface between two tissues with different structures, and the wave is scattered in different
acoustic impedances. Most of the waves are trans- directions. Scattering occurs when a sound wave
mitted into the tissue, and part of the beam will strikes an object that is equal to or smaller than

10
 Simple terminology definitions

the wavelength. Scattering is therefore directly Transducer backing material: This material is placed
related to the frequency of the wave. behind the crystals to dampen vibrations from
them and shorten the pulse duration.
Sound: Energy transmitted as a mechanical, longi-
tudinal wave that requires a medium through Transducer housing: This housing consists of dura-
which to travel (see Fig. 2.1). ble metal and plastic, enclosing the transducer to
protect it from damage.
Spatial resolution: The minimum distance between
two adjacent features that can be detected by the Transducer orientation: Convention dictates the ori-
imaging system. entation of the transducer relative to the patient.
This results in a display which demonstrates the
Specular reflectors: These are strong reflectors and,
patient’s head to the left of the screen during a sag-
as a result, the brightness of the echoes in the
ittal (or longitudinal) scan, and the patient’s right
image is dependent on the angle of the incident
side on the left of the screen during a transaxial (or
beam and the reflector surface.
transverse) scan. Therefore images are always
Temporal resolution: The ability to accurately por- viewed as if from the patient’s right side during a
tray movement occurring within the field of view sagittal scan, and as if from the patient’s feet dur-
during real-time imaging. ing a transaxial scan. Transducers have an embed-
ded indicator that must be correctly aligned with
Texture: In B-mode scanning, the amplitudes of
the corresponding indicator on the monitor, in
the returning signals are displayed on a gray scale
order to ensure correct display of the scanning
from white (strong echo) to black (no echo per-
plane.
ceived) and in-between shades of gray. The
arrangement of reflected echoes as ‘dots’ on the Ultrasound beam: This is composed of a near zone
image is referred to as the texture. or Fresnel zone where the beam is cylindrical in
shape (the area between the transducer and the
Time gain compensation (TGC) or depth gain compen-
focus); a focal zone (the area where the diameter
sation (DGC): This is required in order to compen-
of the sound beam is at a minimum and the image
sate for the fact that signals returning from deeper
quality is best); and a far zone or Fraunhofer
reflectors will be weaker than signals returning
zone where the beam diverges (the area extending
from more shallow reflectors, because of attenua-
beyond the focus).
tion. Increasing TGC amplifies signals more from
deeper structures (that is, those that are relatively Wavelength: The length of one cycle, usually
more delayed – hence, time gain) than it does from measured in mm. As the frequency becomes
shallow structures (that is, less delayed). higher, the wavelength becomes shorter. Con-
versely, as the frequency becomes lower, the wave-
Transaxial (transverse) plane: Divides the body into
length becomes longer (see Fig. 2.1).
superior and inferior sections, perpendicular to
the long axis.
Further reading
Transducer: A device which converts one form of
Hedrick WR, Hykes L, Starchman DE 1995 Ultrasound physics
energy to another. An ultrasound transducer con- and instrumentation, 3rd edn. Mosby, St Louis.
verts electrical energy into sound energy, and vice Sanders RC 1991 Clinical sonography: a practical guide, 2nd
versa. It contains the piezoelectric crystals which edn. Little, Brown, Boston.
transmit the ultrasound beam and receive the Zagzebski JA 1996 Essentials of ultrasound physics. Mosby-Year
reflected echoes. Book, St Louis.

11
This page intentionally left blank
 The piezoelectric effect
3
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 Explain what is meant by the piezoelectric

The piezoelectric effect 13
effect.
Piezoelectric materials 13
2 Describe how piezoelectric crystals are used
The piezoelectric crystal as for the production and detection of sound.
a transmitter of sound 14
3 Explain what is meant by the resonant
The piezoelectric crystal as a receiver frequency of a piezoelectric crystal.
of sound 15
4 Describe the factors which determine the
Production of a pulsed sound wave 16 output frequency of a piezoelectric crystal.
Resonance 16
Factors affecting wavelength/
frequency 16
Important properties of piezoelectric ......................................................
THE PIEZOELECTRIC EFFECT
materials 16 This is the ability of a material to generate an elec-
trical charge in response to applied pressure. When
a piece of piezoelectric material is compressed a
potential difference is generated across opposite
faces – the one side becomes positive, the other
negative (Fig. 3.1). Conversely, if an electric field
is applied across the crystal it changes its shape
(Fig. 3.2).

......................................................
PIEZOELECTRIC MATERIALS
This property is exhibited by certain crystalline
materials such as quartz, which is a naturally
occurring crystal, and lead zirconate titanate,
which is a man-made ceramic.
Piezoelectric materials are crystalline materials
composed of dipolar molecules, which are posi-
tive at one end and negative at the other
(Fig. 3.3). Normally these dipolar molecules have
a random arrangement within the material and
they are unable to align themselves with an
applied electric field (Fig. 3.4). However, if the
material is heated above the Curie temperature in
the presence of an electric field, the molecules will
13
3 Ultrasound physics and technology

Pressure – Applied electric field

+ve
+ + + + + + + + + + + + + + + + + + +

–ve
––––––––––––––––––––––––––

+
Fig. 3.5 · When material is heated above the Curie
temperature in the presence of an electric field,
the molecules will align themselves with the field
Fig. 3.1 · Compression of a piezoelectric crystal
results in a potential difference across opposite faces

Conducting plate

+
Fig. 3.6 · Opposite faces of the crystal have conducting
No electric field Electric field applied
plates attached to their surfaces. These surfaces are at
Crystal changes shape
right angles to the previously applied electric field
Fig. 3.2 · When an electric field is applied to a
piezoelectric crystal it changes its shape
align themselves with that field. If the material is
then allowed to cool below the Curie temperature,
while the electric field is maintained, the mole-
cules will remain aligned to the electric field and
+ve maintain this position even after the field is
removed (see Fig. 3.5). This piezoelectric crystal
–ve can now be used in an ultrasound transducer to
transmit and to detect sound. Opposite faces of
the crystal have conducting plates attached to their
Fig. 3.3 · A dipolar molecule having positive and surfaces. These surfaces are at right angles to the
negative regions previously applied electric field (Fig. 3.6).

THE PIEZOELECTRIC CRYSTAL AS

......................................................
A TRANSMITTER OF SOUND
+ve In this case the crystal is converting electrical
Dipolar molecule energy into mechanical energy. A voltage is applied
–ve to the conducting plates causing the molecules to
twist in the direction of the electric field and this
causes the crystal to become thicker (Fig. 3.7). If
this voltage is reversed the molecules will twist
Fig. 3.4 · Random arrangement of dipolar molecules back in the opposite direction making the crystal
within the piezoelectric material thinner (Fig. 3.8). Applying an alternating voltage
14
 The piezoelectric effect

+ve to the crystal will cause it to expand and contract

(oscillate) at the same frequency as the voltage,
–ve producing a continuous sound wave of that fre-
quency. The degree of expansion and contraction
– + is known as the amplitude of oscillation and is
dependent partly on the voltage. Increasing the
applied voltage increases the amplitude of oscilla-
tion. The amplitude of oscillation is also depen-
Fig. 3.7 · A voltage is applied to the conducting dent on the resonant frequency of the crystal (see
plates causing the molecules to twist in the direction below).
of the electric field and this causes the crystal to
become thicker

THE PIEZOELECTRIC CRYSTAL AS

+ve ......................................................
A RECEIVER OF SOUND
In this case the crystal is converting mechanical
–ve energy into electrical energy. When a sound wave
makes contact with a piezoelectric crystal the
– + regions of high pressure and low pressure cause
the crystal to contract and expand. This twists the
dipolar molecules which results in the conducting
plates becoming charged either positive and nega-
Fig. 3.8 · If this voltage is reversed the molecules tive or negative and positive (Fig. 3.9). In other
will twist back in the opposite direction making the words, small voltage signals are produced from
crystal thinner the sound wave. The size of the voltage signal

Low High High pressure Low pressure

pressure pressure half cycle half cycle
––––––––––––––––––––––––––

+ + + + + + + + + + + + + + + + + + +

+ –

Pulse of
ultrasound
Fig. 3.9 · When a sound wave makes contact with a piezoelectric crystal it results in the conducting plates
becoming charged either negative and positive or positive and negative
15
3 Ultrasound physics and technology

produced depends upon the amplitude (loudness B-mode Pulsed Doppler

or strength) of the sound wave. Sound with higher
amplitude results in a signal with a higher voltage.

Amplitude
Amplitude
PRODUCTION OF A PULSED
......................................................
SOUND WAVE
The process described above is for the production
Frequency Frequency
and detection of a continuous sound wave, the fre-
quency of the sound wave being equal to the fre- Fig. 3.10 · Amplitude versus frequency graphs for a
quency of the applied voltage. However, when B-mode and pulsed Doppler ultrasound
producing a pulsed sound wave the crystal is sub-
jected to a very short pulse of high voltage electric-
ity, typically 500 V and 1 microsecond, which
of a single frequency equal to the frequency of the
produces a pulse of sound approximately 2 wave-
applied voltage. For pulsed Doppler ultrasound a
lengths long. The frequency of the sound pro-
longer pulse of ultrasound is applied, typically
duced depends upon the thickness of the crystal.
8–10 wavelengths long. This emits a short pulse of
In fact, the natural frequency of the crystal is such
sound with a center frequency equal to that of the
that the wavelength of the pulse of sound emitted
applied voltage. Although there are a range of fre-
equals twice the thickness of the crystal.
quencies present in this pulse, the range is narrower
than that produced in B-mode imaging (Fig. 3.10).
......................................................
RESONANCE
This is is the tendency of an object to oscillate at IMPORTANT PROPERTIES OF
maximum amplitude at a certain frequency. For
example, if a series of voltages of different frequen-
......................................................
PIEZOELECTRIC MATERIALS

cies are applied to a piezoelectric crystal, the sur-

Acoustic Impedance
faces of the crystal will oscillate at the frequency The acoustic impedance of the piezoelectric crystal
of the applied voltage. However, at a certain fre- should be chosen so that it is as close to the acous-
quency the amplitude of the oscillation will be tic impedance of the patient’s skin as practicable.
much greater than at any other frequency. This is This is to ensure that there is efficient transfer of
known as the resonant frequency or natural fre- sound energy between the crystal and the patient.
quency of the crystal. If there is a large acoustic impedance mismatch
between crystal and the patient’s skin then a large
amount of energy is reflected at the interface and
FACTORS AFFECTING WAVELENGTH/ only a small amount transmitted. This affects both
......................................................
FREQUENCY the transmission and reception of sound.
The frequency output from a piezoelectric crystal
depends upon the thickness of the crystal and the
type of voltage applied to the crystal. For B-mode
Energy Conversion Efficiency
ultrasound a short pulse of high voltage electricity This is the efficiency of the piezoelectric crystal to
is applied. This is typically 500 volts and 2 wave- convert electrical energy into sound energy and
lengths long. In this case the crystal emits a range to convert sound energy into electrical energy.
of frequencies, with the center frequency equal to Both types of conversion efficiency (electricity into
the resonant frequency. With continuous Doppler sound and sound into electricity) are important in
ultrasound a continuous alternating voltage is ensuring efficient production of ultrasound and
applied to the crystal, which emits a sound wave sensitivity in detecting weak echoes.

16
 The piezoelectric effect

SUMMARY
· The piezoelectric effect is the ability of a material to generate an electrical charge in response to applied
pressure
· Piezoelectric materials also respond to an applied electric field by changes to their shape
· Piezoelectric crystals are used in the production of ultrasound by converting electrical energy into mechanical
energy (sound)
· Piezoelectric crystals are used in the detection of ultrasound by converting mechanical energy (sound) into
electrical energy
· Piezoelectric crystals have a natural frequency (resonant frequency) at which they produce oscillations of
maximum amplitude. The resonant frequency depends upon the thickness of the crystal
· The frequency of the emitted sound depends upon the frequency of the applied voltage, the thickness of the
crystal, and the type of imaging modality being used
· The ability of the crystal to produce ultrasound efficiently, transmit it into the patient, and be sensitive to weak
echoes depends on the acoustic impedance of the piezoelectric crystal and its energy conversion efficiency

17
This page intentionally left blank
 Acoustic impedance
4
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 Describe what is meant by the term acoustic

Acoustic impedance and reflection 20
impedance.
Intensity reflection coefficient 21
2 Explain the properties of a substance which
The intensity reflection equation 21 determine its acoustic impedance.
Acoustic impedance and ultrasound 3 List a set of body tissues in order of their
imaging 21 acoustic impedance.
4 Describe how the amount of ultrasound
energy reflected at the interface between two
substances is determined by their acoustic
impedances.
5 Give the meaning of the term intensity
reflection coefficient.
6 Explain why ultrasound is good at imaging
different soft tissues but poor at imaging
soft tissue/bone and soft tissue/air.

Acoustic impedance (Z) is the property of a sub-

stance, which describes how the particles of that
substance behave when subjected to a pressure
wave, i.e. a sound wave. Acoustic impedance gives
the relationship between excess pressure P and
particle velocity U0 as shown in Figure 4.1.
If the substance has densely packed particles,
for example bone, then it will take a high excess
pressure for them to move at a given velocity.
Therefore this type of substance will have high
acoustic impedance.
On the other hand if the substance has loosely
packed particles, for example air, then it will take
a much lower excess pressure for them to move
at the same velocity. Therefore this type of sub-
stance will have low acoustic impedance.
Acoustic impedance gives a measure of the resis-
tance a substance has to the propagation of a

19
4 Ultrasound physics and technology

......................................................
ACOUSTIC IMPEDANCE AND REFLECTION
When an ultrasound beam strikes an interface
between substances it is the acoustic impedances
Particle p of the two substances that determine whether
traveling at velocity U0 reflection takes place and the amount of energy
reflected. The examples below illustrate this.
Due to excess pressure P
In substances with the same acoustic impedance
Fig. 4.1 · A particle subjected to excess pressure P there is total transmission of energy and therefore
traveling at velocity U0. This gives the acoustic no reflection, see Figure 4.2.
impedance formula:
In substances with a small difference in acoustic
EXCESS PRESSURE P impedance a small amount of energy is reflected
Acoustic impedance Z ¼ ¼
PARTICLE VELOCITY U0 but the majority is transmitted, see Figure 4.3.
In substances with a large difference in acoustic
impedance there is a large amount of reflected
sound wave through it. It is normally calculated
energy and a small amount of transmitted energy,
from density r and speed of sound c as follows:
see Figure 4.4.

Z ¼ rc
excess pressure P
density r kg/m3 Acoustic impedance Z =
particle velocity = U0
speed of sound c m/s
acoustic impedance Z rayls (¼ kg/m2/s) Z1 = Z2
Interface
Z1 Z2
In this book, speed and velocity have the same
meaning. The acoustic impedance of various sub-
stances is given in Table 4.1.

ACOUSTIC IMPEDANCE 100% transmission

SUBSTANCE SPEED
IN MEGARAYLS
(kg/m2/s)  106
(m/s) Fig. 4.2 · Total transmission of ultrasound energy as
it passes across an interface between two substances
of the same acoustic impedance
Air 0.0004 330
Fat 1.38 1450

Water 1.48 1480 Z1 < Z2 or Z1 > Z2

Interface
Blood 1.61 1570
Z1 Z2
Kidney 1.62 1560

Liver 1.65 1550

Muscle 1.70 1580
Soft tissue 1.63 1540
(average)
Bone 7.80 3500 1–5% reflection 95–99% transmission
PZT (Crystal) 30 3870 Fig. 4.3 · A small amount of reflected energy and
a large amount of transmitted energy as ultrasound
Note: the acoustic impedances of air and bone are very different. passes across an interface between two substances
Table 4.1 The acoustic impedance of various substances with a small difference in acoustic impedance
20
 Acoustic impedance

Z1 << Z2 or Z1 >> Z2
Interface
Ir ðZ1  Z2 Þ2
Z1 Z2
R¼ ¼
Ii ðZ1 þ Z2 Þ2
Ir ¼ reflected intensity
Ii ¼ transmitted intensity
Z1 and Z2 ¼ acoustic impedances of the two substances

Example
What is the intensity reflection coefficient R for an inter-
40–99% reflection 1–60% transmission face between liver (Z1 ¼ 1.65 Mrayls) and fat (Z2 ¼ 1.35
Mrayls)?
Fig. 4.4 · A large amount of reflected energy and
a small amount of transmitted energy as ultrasound ðZ1  Z2 Þ2 ð1:65  1:35Þ2 ð0:3Þ2
passes across an interface between two substances R¼ ¼ ¼
with a large difference in acoustic impedance ðZ þ Z Þ2 ð1:65 þ 1:35Þ2 ð3:0Þ2
 1 2 2
0:3
¼
......................................................
3:0
INTENSITY REFLECTION COEFFICIENT
¼ (0.1)2 ¼ 0.01 ¼ 1.0%
This gives the proportion of energy reflected from
an interface between two substances and has a
value between 0 and 1, where 0 ¼ total transmis-
sion and 1 ¼ total reflection. ACOUSTIC IMPEDANCE AND
The intensity reflection coefficient for various
interfaces is given in Table 4.2. ......................................................
ULTRASOUND IMAGING
For most soft tissue/soft-tissue interfaces the The difference in acoustic impedance between two
percentage of energy reflected is 1% or less. substances is known as the acoustic impedance
mismatch. It is this acoustic impedance mismatch
at an interface which is responsible for ultrasound
......................................................
THE INTENSITY REFLECTION EQUATION energy being reflected back toward the probe and
being used to produce an image.
This equation allows you to calculate the intensity
If there is a large acoustic mismatch, e.g.
reflection coefficient (R) for an interface between
between bone and muscle or air and soft tissue,
two substances providing you know their acoustic
then a large proportion of energy is reflected.
impedances.
This results in a strong echo, which produces a
bright image on the display. However, very little
energy is transmitted across the interface and
any echoes produced beyond the interface do
INTERFACE INTENSITY PERCENTAGE not have enough energy to produce an image,
REFLECTION OF ENERGY
COEFFICIENT R REFLECTED (%R) see Figure 4.5.
If the acoustic impedance mismatch is small,
Fat/Muscle 0.0108 1.08 e.g. between two soft tissues, then a small propor-
tion of energy (1% or less) is reflected. The rest of
Bone/ 0.412 41.2 the energy is transmitted across the interface to
Muscle
produce further echoes from other interfaces deep-
Air/Soft 0.999 99.9 er within the subject, see Figure 4.6.
tissue From the above it can be seen that where there
Note the high reflection coefficients for bone/muscle and air/soft is a large acoustic impedance mismatch across an
tissue. interface, ultrasound will not produce a useful
Table 4.2 The intensity reflection coefficient for various image beyond that interface. Therefore it is not
interfaces practical to use ultrasound to produce images of
21
4 Ultrasound physics and technology

Z1 << Z2 or Z1 >> Z2
Interface
Z1 Z2

Fig. 4.6 · Diagram showing echoes reflected from a

series of soft tissue/soft-tissue interfaces

40–99% reflection 1–60% transmission

Fig. 4.5 · Diagram showing an interface with strong
reflection but poor transmission/penetration
discriminating between substances with small dif-
ferences in acoustic impedance and is therefore
soft-tissue subjects which contain gas or bone. excellent at differentiating between different types
However, ultrasound imaging is very good at of soft tissues.

SUMMARY
· Acoustic impedance describes how the particles of a substance behave when subjected to a pressure wave
· Acoustic impedance also gives a measure of the resistance a substance has to the propagation of a sound wave
through it
· A substance which has densely packed particles will have a high acoustic impedance
· A substance which has loosely packed particles will have a low acoustic impedance
· It is the acoustic impedance mismatch between two substances that determines the amount of energy reflected
at an interface
· Soft tissue/air and soft tissue/bone interfaces produce strong reflections because of the large acoustic
impedance mismatch between these substances. However, there is not enough energy transmitted to produce a
useful image beyond these interfaces
· Ultrasound imaging is very good at discriminating between substances with small differences in acoustic
impedance such as soft tissues

22
 The ultrasound beam
5
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 Describe the factors affecting the shape and

Beam shape 23
uniformity of the ultrasound beam.
Intensity of the beam 24
2 Explain the difference between beam width
Side lobes 24 and slice thickness.
Beam width 25 3 List the features of the ultrasound beam which
can give rise to artifacts.
Slice thickness 25
Focusing the beam 25
The beam former 26

......................................................
BEAM SHAPE
The area through which the sound energy emitted
from the ultrasound transducer travels is known as
the ultrasound beam. The beam is three-dimen-
sional and is symmetrical around its central axis.
It can be subdivided into two regions: a near field
(or Fresnel zone) which is cylindrical in shape,
and a far field (or Fraunhofer zone) where it
diverges and becomes cone-shaped (see Fig. 5.1).
The actual shape of the beam depends on a
number of factors, including the diameter of the
crystal, the frequency and wavelength, the design
of the transducer, and the amount of focusing
applied to the beam. Increasing the frequency will
result in a longer near field and less far field diver-
gence. A narrow crystal diameter will result in a
narrower beam in the near field, but the disadvan-
tage is that the near field is shorter and there is
more divergence in the far field.
Where there is continuous sound output from a
transducer (primarily Doppler applications), there
will be sound energy present throughout the beam
for the duration of the scanning period. Most diag-
nostic applications, however, use pulsed sound,
where the output is a series of short pulses of
sound. In this case sound energy is not present

23
5 Ultrasound physics and technology

its width. This is caused by a number of variable

Transducer factors such as:
l the beam does not have clearly defined edges

and the intensity will decrease from the

center outward
l the beam diverges which leads to the power

Fresnel zone distributing over a larger area in the far field

l interference effects exist in the near field from

the numerous point sources of which the

crystal is composed. A broadband transducer
(see Chapter 6 on Transducers), due to its
numerous frequency components, will show
Fraunhofer zone
fewer interference effects and therefore more
uniformity.
One noticeable result of the non-uniformity of
intensity in the beam is that during scanning, a
Fig. 5.1 · Beam shape small reflector will give rise to a stronger echo if it
is in the center of the beam (where there is maxi-
mum intensity of energy) than if it is on the periph-
ery. This can therefore lead to a false interpretation
by the operator as to the density of the reflector.
Where the beam is focused to improve spatial
resolution, this will cause further non-uniformity
of intensity, because a narrower beam will be cre-
ated within the area known as the focal zone. The
intensity is greatest in the focal zone and therefore
a stronger echo will be received from a given struc-
Continuous Pulsed ture that lies within the focal zone.
ultrasound ultrasound
beam beam

......................................................
SIDE LOBES
Some of the energy from the transducer radiates
at various angles to the transducer face, and these
are known as side lobes. There may be one or more
Fig. 5.2 · Pulsed and continuous wave ultrasound of these, and each of them will also be three-dimen-
beam
sional and will be the same frequency as the main
lobe (see Fig. 5.3). Any interfaces encountered by

throughout the beam, but only in small areas or Transducer

pockets. It is the movement of these pockets of
sound which we refer to as the ultrasound beam
(see Fig. 5.2). Side lobes

......................................................
INTENSITY OF THE BEAM
The intensity of the beam is the power (measured in Main beam
watts) flowing through a unit area (see Chapter 12
on Ultrasound safety). The intensity is not
uniform throughout the beam’s length nor across Fig. 5.3 · Side lobes
24
 The ultrasound beam

......................................................
any of these side lobes will return echoes to the
SLICE THICKNESS
transducer, which the equipment erroneously
assumes to have been received by the main beam. The ultrasound image viewed on the monitor is
These echoes will therefore be incorrectly placed a three-dimensional volume displayed as a two-
(or misregistered) on the image (see Chapter 9 on dimensional image. The slice thickness refers to
Artifacts). Approximately 15% of the energy in the the dimension of the beam at 90 to the scan
beam will be within the side lobes. Manufacturers plane (see Fig. 5.4). Where the transducer has a
continually attempt to limit the amount of side circular crystal aperture, because the beam is sym-
lobes but are unable to eliminate them completely. metrical about its central axis, at any distance from
Array transducers will, in addition to the side the transducer, the beam width and slice thickness
lobes, also have grating lobes, which are lobes at are equal. However, where transducers have rect-
various angles to the main beam. These only exist angular apertures (phased array or linear array)
in the direction along which there are multiple ele- the beam width and slice thickness can be very
ments within the array. Both side lobes and different. The slice thickness is usually larger than
grating lobes can lead to considerable artifacts the beam width and cannot easily be reduced.
due to the three-dimensional misregistration The fact that the beam width and the slice thick-
which inevitably occurs. In addition, they cause a ness are not finite results in artifacts occurring in
degradation of lateral resolution due to the effec- the image (see Chapter 9 on Artifacts).
tive widening of the beam in the scan plane.

......................................................
FOCUSING THE BEAM
......................................................
BEAM WIDTH The ultrasound beam can be focused, during both
Beam width refers to the dimension of the beam transmit and receive, to improve the quality
in the scan plane, or the plane through which within a particular zone of the image. This can
the beam is sweeping (see Fig. 5.4). The actual be carried out in a number of ways (see Chapter 6
beam width will vary according to the distance on Transducers) but the objective is to cause the
from the transducer, particularly where focusing beam to converge, which results in a narrowing
is used. The width of each pulse of sound will of the beam (see Fig. 5.5). The operator can alter
therefore change with depth. The beam width the depth of the focal zone or the number of focal
affects the spatial resolution of the image (the abil- zones. Increasing the number of focal zones will
ity of the operator to distinguish small structures)
and generally, the narrower the beam width, the
better the spatial resolution.
Transducer

Focal zone where the

beam is caused to narrow

Slice Beam width

thickness Fig. 5.5 · Focusing of the ultrasound beam results in
Fig. 5.4 · Beam width and slice thickness narrowing of the beam

25
5 Ultrasound physics and technology

increase the size of the area with improved resolu- connection to transmit the beam and receive the
tion, but will result in a slower frame rate of the echoes. By manipulating the sequence of firing of
image and poor temporal resolution (ability to these elements, the direction of propagation of
visualize moving structures). the beam can be altered. This process is controlled
by the beam former which can be manipulated by

......................................................
the operator. The beam former will control a vari-
THE BEAM FORMER
ety of functions such as the focusing, beam steer-
An array transducer has multiple crystal elements ing, and switching between B mode and Doppler
(up to 128) and each has its own electrical (see Chapter 6 on Transducers).

SUMMARY
· The ultrasound beam is three-dimensional and is symmetrical about its axis
· The shape of the beam depends on a number of factors, including the diameter of the crystal, the frequency and
wavelength, the design of the transducer, and the amount of focusing applied to the beam
· The intensity of the beam is not uniform throughout its entire volume
· Inherent characteristics of the beam can lead to a number of artifacts such as side lobe artifacts, beam width
artifacts, and slice thickness artifacts
· Manufacturers use a variety of technological features to optimize the beam, improve resolution, and reduce the
artifacts

26
 Transducers
6
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 List the basic components that are used in the

Introduction 27
construction of a typical diagnostic ultrasound
The transducer 28 transducer.
Electronic multi-array transducers 31 2 Understand the operation of these devices.
Forming ultrasound images 32 3 Understand how ultrasound images are
formed.
Electronic beam focusing and
steering 33 4 Explain how transducers can electronically
focus and steer the ultrasound beam.
Types of electronic array transducers 36
5 List the different types of electronic array
transducers.

......................................................
INTRODUCTION
The transducer is one of the most critical compo-
nents of any diagnostic ultrasound system. There
are many types of ultrasound transducers that
can be selected before performing an ultrasound
investigation as seen in Figure 6.1, and a great deal
of attention should be paid to selecting the most
appropriate transducer for the application.
Ultrasound transducers are described by their
type and operating frequency which can range
from 2 MHz up to 20 MHz and are selected based
on their ‘fitness for purpose’. The end user must
recognize that different applications require an
appropriately selected transducer which is best
suited for a particular investigation.
We need to be aware that there is a trade-off
between image resolution and the penetrating
depth of ultrasound which is governed by its fre-
quency. For example, a 12 MHz transducer has
very good resolution, but cannot penetrate very
deep into the body compared to a 3 MHz trans-
ducer which can penetrate deep into the body,

27
6 Ultrasound physics and technology

Components and Construction of a Typical

Transducer
There are many types of transducers ranging from
a simple single element to electronic multi-array
probes which have hundreds of elements. The
components and construction of these different
types of transducers are principally the same. To
understand how modern day electronic multi-
element transducers function we need to start by
considering the construction and components of
a simple single element circular transducer. This
Fig. 6.1 · Ultrasound transducers (With permission is illustrated in Figure 6.2.
from Toshiba Medical Systems.) The main components of a typical ultrasound
transducer consist of:
l physical housing assembly

l electrical connections

l piezoelectric element
but the resolution is not as good as the transducer
l backing material
operating at 12 MHz. In general use, the highest
l acoustic lens
frequency transducer which will reach the required
l impedance matching layer.
depth should always be employed.
Physical housing

......................................................
THE TRANSDUCER This contains all the individual components
including the crystal, electrodes, matching layer,
Diagnostic transducers act as both a transmitter
and receiver of ultrasound and are able to produce and backing material. This housing provides the
beams which can be directed in various ways to necessary structural support and acts as an electri-
improve the quality of the images that we see on cal and acoustic insulator.
screen. Electrical connections
The primary component of the transducer is
made from a piezoelectric material which means Two electrical connections are formed on the front
they are able to convert one form of energy to and back face of the crystal by plating a thin film
another, in this case electrical energy into mechan- of gold or silver on these surfaces. These electrodes
ical energy and vice versa. are connected to the ultrasound machine which

Protective
front layer λ/2 thick

Matching layer
(λ/4 thick)

Transducer housing Backing Piezoelectric Acoustic

material crystal lens
Fig. 6.2 · The construction and components of a simple single element circular transducer

28
 Transducers

generates the short burst of electrical pulses to appreciate that thinner piezoelectric materials pro-
excite the crystal and through the piezoelectric duce higher resonant frequencies. Typical diagnostic
effect generates a pulse of ultrasound energy. ultrasound elements are between 0.2 mm and 1 mm
thick.
Piezoelectric element A transducer operating at a resonant frequency
Transducers operate on the piezoelectric effect of 2 MHz would have a thickness around 1 mm.
which was discovered by Jacques and Pierre Curie In comparison, a transducer operating at a much
in 1880. They found that certain crystalline minerals higher frequency, say 7.5 MHz, would have a typi-
when subjected to a mechanical force became elec- cal thickness of 0.3 mm.
trically polarized which means that they generated
voltages. They also discovered that the converse Purpose of the backing material
was true, i.e. if a short electrical burst was applied
Let us consider a simple single element transducer
to these crystals it would cause them to vibrate.
as illustrated in Figure 6.3. When a short burst or
The term ‘piezoelectric’ was derived from the Greek
pulse of electricity is applied to a crystal it causes
word ‘piezein’, meaning to press or squeeze.
it to vibrate in all directions. The main vibrations
By utilizing this piezoelectric property an ultra-
come from the front and back faces of the pie-
sound transducer can act both as a transmitter
zoelectric crystal. We are only interested in the
and receiver of ultrasound.
vibrations that come off the front face of the trans-
In transmission mode, a short burst of electric
ducer. To try and eliminate the vibrations from the
energy generated by the ultrasound scanner (typi-
back face, and to control the length of vibrations
cally one to three cycles of alternating voltage for
from the front face, a backing or damping material
imaging) is sent to the transducer generating an
is used. This damping material, which typically
ultrasound pulse of energy. Reflected ultrasound
consists of tungsten powder and plastic or epoxy
echoes returning to the transducer face are detected,
resin, is attached to the back face of the piezoelec-
causing mechanical vibrations which are converted
tric crystal.
into electrical voltages. It is these electrical signals
Figure 6.4 shows that without the backing mate-
that are processed by the ultrasound machine
rial a longer pulse of ultrasound is generated by a
which form the images that we see.
short burst of electricity as the crystal continues to
What are they made of? vibrate or rings. These vibrations naturally fade
Quartz is a naturally occurring material with piezo- out with time. An example of this effect can be
electric properties and was extensively used in the heard when a cymbal is hit by a drumstick and con-
development of early machines. This has now been tinues to ring for some time. Attaching a backing
superseded by man-made ceramics such as lead material on the rear face of the element dampens
zirconate titanate (PZT) which are more efficient, the vibrations and generates a shorter ultrasound
have better sensitivity, and can easily be shaped. pulse. The length of the ultrasound pulse is known
as the spatial pulse length (SPL).
How do you determine a transducer’s Ultrasound pulses which are used for imaging
operating frequency? are typically two to three cycles long. The advantage
The operating frequency of a transducer is criti- of having a short ultrasound pulse for diagnostic
cally governed by the thickness of the piezoelec- imaging is that it improves the resolution of the
tric crystal. For maximum efficiency the crystal ultrasound images and in particular improves the
should be operating at its ‘natural’ or ‘resonant’ axial resolution.
frequency. This occurs when the thickness of the However, the damping material makes the
crystal corresponds to half a wavelength (l/2). generation of ultrasound less efficient and also
We have already discovered that wavelength reduces the sensitivity of the transducer to detect
and frequency are inversely related, i.e. as wavelength weak echoes. This is the price to pay for improved
decreases frequency increases, therefore we can resolution.

29
6 Ultrasound physics and technology

+ –

– +

An alternating voltage applied across Main vibrations come from the front and back
the crystal causes it to vibrate faces of the crystal
Fig. 6.3 · When a short pulse of electricity is applied across the crystal it causes it to vibrate. The main vibrations are
generated from the front and back face of the crystal

Excitation
voltage pulse Crystal Ultrasound pulse wave

Long spatial
Backing material pulse length

Backing material stops back face Short spatial

from vibrating and dampens the length pulse length
Fig. 6.4 · The effect of a backing material is to eliminate any vibrations from the back face of the crystal and to
produce a short pulse of ultrasound

Acoustic lens (Fig. 6.5a) or by using a curved piezoelectric crys-

tal (Fig. 6.5b). The lateral resolution of an ultra-
The purpose of the acoustic lens is to improve
sound beam varies with depth and is best at the
image resolution by reducing the beam width of
focal region where the beam is narrowest.
the transducer. The width of the beam determines
the lateral resolution. The lateral resolution is the
Impedance matching layers
ability to resolve structures across or perpendicular
to the beam axis. For a single element transducer An acoustic impedance matching layer is sand-
sound may be focused by the addition of a lens wiched between the piezoelectric crystal and the
30
 Transducers

A
Focal zone

Focused with the

addition of a lens Depth

B
Focal zone

Focused by a The beam width of a focused ultrasound beam varies

curved crystal with depth and is narrowest at the focus.
Best lateral resolution is achieved at the focus.
Fig. 6.5 · Focusing of the ultrasound beam achieved by a) utilizing a lens or b) using a curved piezoelectric
crystal. Ultrasound beam is narrowest at the focal zone

patient and is an important factor that affects the the pulse in fact contain a range of frequencies
sensitivity of the transducer, i.e. the ability of the which are centered around this operating fre-
ultrasound system to detect small reflected echoes. quency. The range of frequencies contained within
A large difference in acoustic impedance (Z) an ultrasound pulse is referred to as its bandwidth.
between two objects results in a large reflection One of the factors that affect the bandwidth of a
of the incident ultrasound beam. The difference transducer is the spatial pulse length. Pulses which
in acoustic impedance between the crystal and soft have short spatial pulse lengths contain a wider
tissues within the patient is large (>15 times), and range of frequencies, i.e. have a wide bandwidth.
without this matching layer, most of the acoustic On the other hand, ultrasound pulses which have
energy (typically 80%) would be reflected at this longer spatial pulse lengths contain a narrower
boundary with only around 20% being transmit- range of frequencies, i.e. have a narrow bandwidth.
ted into the patient. This is illustrated in Figure 6.6.
The matching layer typically has an acoustic The wideband characteristics of modern day
impedance value halfway between that of the crystal ultrasound transducers results in the end user
and soft tissue. This results in more transmitted being able to simply push a button to switch to a
energy entering the patient and improves the signal higher or lower operating frequency rather than
strength of any returning echoes, which in turn changing the transducer. This enables the operator
improves the ultrasound system’s sensitivity and to choose a higher frequency to provide better
image resolution. detail resolution (resulting in some loss to the
More than one matching layer can be used and penetrating depth of the ultrasound beam) and
they are typically constructed to be one quarter switching to a lower frequency to increase the pen-
wavelength thick (l/4). etration of the ultrasound beam (resulting in some
loss to image quality).
Relationship between Spatial Pulse
Length and Bandwidth ELECTRONIC MULTI-ARRAY
We have discussed how transducers operate at their ......................................................
TRANSDUCERS
resonant frequency which is governed by the thick- Electronic transducers have an array of rectangular
ness of the piezoelectric crystal. However, the short shaped piezoelectric crystals etched side by side
pulses of ultrasound that are produced by damping into one PZT ceramic (see Fig. 6.7a) which is
31
6 Ultrasound physics and technology

Center operating shorten the pulse length, and matching layers

frequency attached to the front face to improve the sound
transmission into the patient.
Typically, there are between 128–256 elements
across the face of these transducers which are indi-
vidually connected through one of the ultrasound
Frequency machine ports. Figure 6.7b shows the hundreds of
Short spatial pulse length = Wide bandwidth
connections at the end of a transducer connector
assembly.
Center operating Being able to control the firing sequence of each
frequency
of the individual elements across the face of a trans-
ducer enables the operator, through the machine’s
front end controls, to manipulate the shape and
direction of the ultrasound beam.
Frequency
Longer spatial pulse length = Narrow
bandwidth ......................................................
FORMING ULTRASOUND IMAGES
Fig. 6.6 · Demonstrating the relationship between Ultrasound images are not created by firing all the
spatial pulse length and bandwidth. The shorter elements in an electronic array transducer at the
ultrasound pulse contains a wider spread of
same time. They are formed by transmitting a series
frequencies known as the bandwidth. In comparison,
a pulse which has a longer pulse duration, i.e. longer of small narrow beams along the transducer face
spatial pulse length, has a narrower bandwidth which are directed along adjacent paths through
the patient to generate one cross-sectional image.
Historically, early transducers were built to have
mounted within the transducer housing. The inter- one crystal which was moved mechanically by a
nal components are similar to the simple single small motor to sweep the beam over an area of the
element transducer that was described earlier, in patient. An example of this early type of mechanical
that they both have a backing material attached transducer is illustrated in Figure 6.8a which pro-
to the back face of the piezoelectric element to duces what is known as a sector field of view.

Backing material

Array of piezoelectric
elements mounted
alongside one another

Matching layers

Fig. 6.7 · a) Internal construction components of an electronic array transducer. b) Picture of the hundreds of
connections at the transducer connector assembly

32
 Transducers

Sector field of view created by early

mechanical transducers
Fig. 6.8 · a) An example of an early mechanical transducer based on a single element which is mechanically
swept over a range of angles to produce a sector field of view. b) A picture of a selection of modern day
multi-element electronic transducers

Although these mechanical transducers can still rectangular image being produced for a linear array
be found, they were superseded by the modern elec- transducer.
tronic transducers that we use today (Fig. 6.8b).
Electronic transducers form an image by using
ELECTRONIC BEAM FOCUSING
small groups of elements (typically 5–10) to pro-
duce a narrow ultrasound beam which forms a ......................................................
AND STEERING
scan line. The ultrasound machine can very rapidly The ultrasound beam generated from electronic
sequentially sweep the position of this beam across array transducers are formed by using groups of ele-
the face of the transducer to produce a cross- ments. These individual elements create small wave-
sectional image as seen in Figure 6.9a. The firing lets that interact with each other to form an overall
sequencing of the groups of elements across a lin- ultrasound beam with a characteristic wavefront.
ear array transducer is illustrated in Figure 6.9b. Consider a group of elements which are all
The first group of elements, in this case 1–5, are excited simultaneously (seen in Fig. 6.10). The indi-
selected to create the first beam to form a scan line. vidual elements create small wavelets which interact
Once all the returning echoes are received then a together to form an ultrasound beam which has a
second group of elements are fired to form an adja- wavefront that travels perpendicular to the face of
cent scan line, again waiting for all the returning the transducer.
echoes to be received before moving onto the next By introducing a set of time delays to the indi-
group and so on. In this case this results in a vidual elements, the ultrasound beam’s shape
33
6 Ultrasound physics and technology

Adjacent ultrasound beams

formed across the
transducer face

B 1 2 3 4 5 6 7 8 9 10 11 12
Excited element
Group 1
Silent element

Group 2
First beam Group 1 Elements 1–5
Second beam Group 2 Elements 2– 6
Group 3 Third beam Group 3 Elements 3–7
Fourth beam Group 4 Elements 4–8

Group 4

Fig. 6.9 · a) Ultrasound beam scanning is performed electronically by sequentially activating small groups of
elements across the face of the transducer. b) Demonstrating the firing sequence for a group of elements across
a transducer face

and direction can be electronically manipulated to

focus and steer the ultrasound beam.

Electronic Beam Focusing

We have already discussed that focusing the ultra-
Wavelets sound beam improves the image quality (resolu-
tion) by making the beam thinner within the focal
zone. A simple single element transducer focuses
Wavefront the beam by either utilizing an acoustic lens or by
using a curved piezoelectric crystal. Electronic trans-
ducers focus the beam by introducing a series of
time delays across a group of elements which are
to be excited. Consider a group of nine elements
which require a beam to be focused at a depth A
Fig. 6.10 · A group of elements are excited (Fig. 6.11).
simultaneously, generating an ultrasound beam with To create a beam which is focused at depth
a wavefront which travels perpendicular to the face A requires all the wavelets created by each individ-
of the transducer ual element to converge, i.e. to arrive at the desired
34
 Transducers

1 2 3 4 5 6 7 8 9

B A B

Wavefront

Focus

Focus (F)
Fig. 6.11 · Path differences between the focal point
and a group of elements
Fig. 6.12 · A typical sequence of time delays
introduced across a group of elements to produce a
focused ultrasound beam
focal point at the same time. We can see that
the distance between the focus and the individual
elements vary. The shortest distance is path A,
between the focus and the center element. The lon-
gest distance, path B, involves the outermost ele-
ments (1 and 9). So to ensure that all the wavelets
arrive at the same point at the same time, the ultra-
sound machine through the beam former intro-
duces a set of time delays across the individual
elements. As the outermost elements (1 and 9) have Single focal zone
the furthest to travel they are excited first, followed
by elements 2 and 8, then 3 and 7 and so on. The
last element to be excited will be element 5. Fig-
ure 6.12 shows a typical sequence of time delays
to produce an electronically focused beam.
Because focusing is achieved by introducing a set
of electronic time delays, the position of the focal
zone can be controlled by changing the timing
sequence of these delays. Greater time delays create
Multiple focal zones
beams which are focused near to the transducer
make overall beam
face. Longer time delays move the focal position thinner
further away from the transducer and deeper into
the patient.
Operators are able to choose more than one
Fig. 6.13 · Effect of multiple focal zones on beam
focus and create beams with multiple focal zones shape
which effectively creates a long narrow beam as
illustrated in Figure 6.13. The advantage of using
multiple focal zones is that overall image quality scan line. The more focal zones selected the more
is improved throughout the image. The main dis- time it takes to form a scan line which results in
advantage is that for each additional focal zone the frame rate being reduced, making the images
another pulse has to be sent out along the same appear disjointed.
35
6 Ultrasound physics and technology

Electronic Beam Steering Linear Array Transducers

The ultrasound beam can also be steered by intro- This type of array is typically made of between
ducing a set sequence of time delays to the trans- 128–256 elements in a row and produces parallel
mit pulses across a group of individual elements. scan lines which are transmitted perpendicularly
The angle at which the beam is produced will to the transducer face resulting in a rectangular
depend on the delay between the excitation pulses field of view (see Fig. 6.15a). The width of this
of the individual elements. A typical sequence of image is approximately equal to the length of the
time delays is demonstrated in Figure 6.14a. An transducer head. Linear array transducers are used
image is formed by electronically sweeping the to image superficial structures and vessels and
direction of the ultrasound beam across the trans- therefore operate at frequencies typically above
ducer face by changing the delay between every set 4 MHz. They are extensively used for vascular,
of excitation pulses so that the ultrasound beam is small parts and musculoskeletal applications.
steered over a wide range of angles to form a wide
‘sector’ field of view (Fig. 6.14b).
Curvilinear Array Transducers
This type of transducer is similar to a linear array
TYPES OF ELECTRONIC ARRAY
but the transducer face is formed into a curve
......................................................
TRANSDUCERS
(convex in shape) which provides a wide field of
All the different types of transducers currently view which diverges with depth (see Fig. 6.15b).
available can be characterized into three main These transducers are sometimes referred to as sec-
types and are illustrated in Figure 6.15. They con- tor arrays. Curvilinear transducers operate at lower
sist of: frequencies compared to linear arrays, typically
l linear array transducers around 3.5 MHz, and are best suited to image deep-
l curvilinear (or sector) array transducers lying structures. Their main applications are in
l phased array transducers. abdominal and obstetric scanning.

B
A

Wavelets

Wavefront Wavefront

Fig. 6.14 · a) Typical time delay patterns introduced across a group of elements to steer the beam through a range
of angles. b) Field of view created by beam steering

36
 Transducers

A B C

Linear array Curvilinear array Phased array

Small footprint

Produces a rectangular Produces a wide ‘sector’ Produces a ‘sector’

field of view field of view field of view
Fig. 6.15 · Three types of electronic array transducers. a) Linear array; b) curvilinear array; c) phased array

Phased Array Transducers from a small transducer contact area, known as a

footprint. The small footprint and wide field of
Phased array transducers are similar to a linear
view of these transducers are typically utilized in
array, being a flat-faced transducer with a row of
cardiac applications where it is difficult to image
elements positioned alongside one another. The
the heart because of the ribcage. These small trans-
crucial difference between the phased array and
ducers can easily fit between the ribs or under-
linear and curvilinear transducers is that the beam
neath the ribcage to obtain an image of the
is electronically steered to produce an image. As a
heart. Typically operating at frequencies similar
consequence of this, phased array transducers have
to curvilinear transducers, they are used to image
a wide field of view similar to that of curvilinear
deep-lying structures and perform specialized trans-
transducers (see Fig. 6.15c).
cranial investigations.
These transducers are physically smaller than
their counterparts and provide a wide field of view

SUMMARY
· Ultrasound transducers operate on the piezoelectric principle
· They convert electric energy into mechanical energy and vice versa; as a consequence of this they act as both a
transmitter and receiver of ultrasound
· The thickness of the piezoelectric crystal determines the operating frequency
· The backing material shortens the ultrasound pulse length which improves axial resolution
· Focusing makes the ultrasound beam thinner, improving lateral resolution
· An ultrasound image is formed by sequentially sending out many adjacent ultrasound beams known as scan
lines
· Modern day electronic transducers consist of an array of 128–256 elements that can be individually controlled by
the beam former
· Electronic transducers can focus and steer the beam by introducing a sequence of varying time delays
· Common types of transducers include linear, curvilinear, and phased arrays

37
This page intentionally left blank
 Resolution
7
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 Define the term resolution as applied to an

Spatial resolution 39
ultrasound image.
Contrast resolution 42
2 Explain what is meant by spatial, contrast, and
Temporal resolution 42 temporal resolution.
Optimizing resolution 43 3 Explain what is meant by axial and lateral
resolution and list the factors affecting them.
4 Describe the factors that affect frame rate.

Resolution is a term which describes the ability of

an imaging system to differentiate between struc-
tures, images, or events and display them as sepa-
rate entities.
In this chapter we are going to examine the fol-
lowing categories of resolution and the factors that
influence them:
l Spatial resolution – resolution in space

l Contrast resolution – resolution of gray

shades
l Temporal resolution – resolution in time.

......................................................
SPATIAL RESOLUTION
This is the ability to display two structures situated
close together as separate images. When the struc-
tures are displayed as separate images we say that
they are resolved (see Fig. 7.1).
In ultrasound imaging the spatial resolution
depends ultimately on the wavelength of the
sound used to produce the image. For example,
the wavelength of a 5 MHz ultrasound beam is
approximately 0.3 mm so it would not be possible
to resolve objects less than 0.3 mm apart using a
5 MHz transducer.

39
7 Ultrasound physics and technology

Axial
Objects Image resolved Image unresolved resolution
Good resolution Poor resolution
Fig. 7.1 · The difference between good resolution
and poor resolution Lateral
resolution

In ultrasound imaging, spatial resolution is

divided into two components: Fig. 7.2 · Axial resolution and lateral resolution on
1 Axial resolution – resolution down the the image produced by a sector scanner
screen
2 Lateral resolution – across the screen (see
Fig. 7.2).

Axial Resolution
Poor axial
This is resolution along the axis of the beam and resolution
depends upon the spatial pulse length – a short
pulse length gives good axial resolution and the Good axial
resolution
best resolution that can be achieved is half the spa-
tial pulse length. For example if the pulse length is
1 mm then structures situated along the axis,
which are less than 0.5 mm apart, will not be Fig. 7.3 · Poor axial resolution and good axial
resolved (see Figs 7.3 and 7.4). resolution

Returning echoes Returning echoes

separated by a gap overlapping and
and therefore resolved therefore not resolved
into separate images into separate images

Pulse Pulse
SPL<2I SPL>2I

Interface Echoes Interface Echoes

separation = I reflected separation = I reflected

Fig. 7.4 · How spatial pulse length (SPL) affects axial resolution
40
 Resolution

Factors affecting spatial pulse Lateral Resolution

length and therefore axial resolution
This is resolution at right angles to the beam and
Frequency Each pulse of ultrasound is approximately depends upon the beam width – a narrow beam
two wavelengths long and therefore a shorter wave- width gives good spatial resolution and the best
length will reduce the pulse length. The wavelength resolution that can be achieved is equal to the
of ultrasound depends on its frequency with the beam width at the focus of the beam (see Fig. 7.6).
higher frequency waves having the shorter wave- The lateral resolution for a particular ultrasound
lengths. Therefore using ultrasound with a higher machine is generally not as good as the axial
frequency for imaging will result in a shorter spatial resolution.
pulse length and improved axial resolution. The beam width determines the size of the
Transducer design The pulse length depends echoes displayed on the screen and structures
upon the amount of damping applied to the pie- must be separated by a distance greater than the
zoelectric crystal. The damping material is used beam width for them to be resolved into separate
to reduce ‘ringing’; this is where the crystal con- images (see Fig. 7.7).
tinues to oscillate and produce sound after the Structures will only be resolved into separate
driving voltage has ceased. Increasing the amount images if the separation between them is greater
of damping makes the pulse length shorter and
therefore improves the axial resolution.

Field of view (FOV)

Axial resolution may be affected by the FOV. In order
for images of two structures to be resolved on the
monitor screen they must be separated by at least Structures to Poor lateral
be imaged resolution
2 pixels, but as the FOV increases the distance
represented by 2 pixels also increases. Therefore if Good lateral
the distance between the images of two structures resolution
is less than 2 pixels they will not be resolved.
The consequence of the above is that using a
large FOV may be detrimental to the axial resolu- Fig. 7.6 · Poor lateral resolution and good lateral
tion (see Fig. 7.5). resolution

Ultrasound beam travel

Structures to
be imaged

At 5 cm depth the two At 15 cm depth the two

structures are separated structures are separated
by 3 pixels and the by 1 pixel and the
images are resolved images are not resolved
Fig. 7.5 · How increasing the depth of the field of Fig. 7.7 · How beam width determines the size of the
view may cause deterioration in axial resolution images displayed

41
7 Ultrasound physics and technology

representing an ultrasound echo is converted into

Ultrasound beam travel a binary number. During this operation there may
be compression and filtering of the signal, which
has an effect on the number of gray scales displayed
Structures to and therefore the contrast resolution.
Unresolved
be imaged
Control settings The following controls affect
contrast and therefore the contrast resolution:
Resolved
l Gain (amplification)

l Time-gain compensation (TGC)

No echoes
returned l Post-processing and pre-processing options
Unresolved
from gap l Harmonic imaging; this improves contrast

l Compound scanning. This improves edge

Fig. 7.8 · How structures must be separated by the definition but has a detrimental effect on
beam width in order to be resolved into separate contrast.
images

than the size of the beam width – the beam must

fit into the gap between the two structures so ......................................................
TEMPORAL RESOLUTION
that it can return ‘no echoes’ from that position This is the ability of the imaging system to display
(see Fig. 7.8). events which occur at different times as separate
images. This is important when looking at rapidly
Factors affecting beam width moving structures such as the heart beating.
and therefore lateral resolution Temporal resolution is determined by the frame
rate, which is the number of images displayed per
Diameter of the piezoelectric crystal (aperture) second. The frame rate depends on a number of
As the aperture increases the beam width close to factors – these are illustrated in Figure 7.9.
the crystal face increases.
Transducer frequency Higher frequency beams Frame rate, pulse repetition
have a longer near field and less divergent far field frequency (PRF) and number of scan lines
so the beam width is narrower than a lower fre- The relationship between the frame rate, PRF and
quency beam in these regions. lines per frame is given by the following formula:
Focusing The degree of focusing, the length of
the focal zone, and the number of focal zones all PRF
frame rate ¼
affect beam width. lines per frame
Distance from the crystal (where lateral resolution is Frame rate depends upon the PRF pulse repetition
measured) The best lateral resolution is found at frequency and the number of scan lines per image:
the focal point of the beam. The beam width
increases the further it is from the focal point.
PRF

......................................................
CONTRAST RESOLUTION
tion
ifica

Sector angle
Contrast resolution is the ability of the imaging
agn

system to differentiate between body tissues and

th/m
Dep

display them as different shades of gray. The main

factors affecting it are as follows: Line density
Transducer design Higher frequency transducers,
which have a smaller slice thickness, generally pro-
vide better contrast resolution.
Analog to digital conversion This is a signal proces-
sing operation where the amplified voltage signal Fig. 7.9 · The factors affecting frame rate
42
 Resolution

Example Lines per frame

PRF ¼ 1000 pulses per s
Number of lines per image ¼ 100 Sector angle
Therefore frame rate ¼ 10 frames per s

Factors affecting pulse repetition frequency

Line density
PRF depends upon image depth; an increase in
image depth results in a lower PRF (see Fig. 7.10).

Factors affecting the number of lines per frame

The number of lines per frame depends upon the
Fig. 7.11 · The factors affecting number of lines per
frame
sector angle and the line density (lines per cm).
An increase in either of these increases the number
of lines per frame (see Fig. 7.11).
......................................................
OPTIMIZING RESOLUTION
In order to optimize spatial resolution, the highest
frequency, consistent with adequate penetration,
should be selected. The ultrasound beam should
also be focused at the area of interest and if move-
PRF
ment of the subject is not a problem then multiple
tion

focal zones can be used.

ifica

Sector angle To optimize contrast resolution, the highest

agn

frequency, consistent with adequate penetration,

th/m

should be selected, together with the appropriate

Dep

preset for the area being examined. Contrast is

also optimized by using the correct overall gain
and TGC settings.
Temporal resolution is improved by imaging at a
high frame rate. This can be achieved by reducing
Fig. 7.10 · The factors affecting pulse repetition the sector angle and depth to include only the area
frequency of interest and selecting a single focal zone.

SUMMARY
· Spatial resolution is the ability of the imaging system to display two structures situated close together as
separate images. When the structures are displayed as separate images we say that they are resolved
· Contrast resolution is the ability of the imaging system to differentiate between body tissues and display them
as different shades of gray
· Temporal resolution is the ability of the imaging system to display events which occur at different times as
separate images. This is important when looking at rapidly moving structures
· Resolution can be optimized by selecting a high frequency, consistent with adequate penetration, and
appropriate adjustment of machine controls

43
This page intentionally left blank
 Ultrasound interactions and
attenuation
8
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 Explain what is meant by the term attenuation.

Attenuation 45
2 Give the factors which influence attenuation.
3 Explain each of the interactions which are
responsible for attenuation.
4 Describe how each of the above interactions
affects the ultrasound image.

......................................................
ATTENUATION
As the ultrasound beam travels through the body it
loses energy. The intensity and amplitude of the
sound wave decreases, and this process is known
as attenuation.
The amount of attenuation that occurs will
depend on the type of tissue the sound wave is
traveling through. Where the molecules of the tissue
are densely packed (such as bone), attenuation will
be much greater than in less densely packed tissue
(such as fat). Different tissues have different attenu-
ation coefficients depending on the amount of
attenuation occurring in the beam of sound.
Attenuation depends on the frequency of the
sound. The higher the frequency, the greater the
amount of attenuation that will occur in any given
tissue.
Attenuation will occur not only in the beam of
sound produced by the transducer as it propagates
through tissue, but also in the returning echoes as
they travel back to the transducer.
It therefore follows that returning echoes from
deep within the patient will be of a much lower
intensity than the initial beam of sound passing into
the patient. It is for this reason that imaging equip-
ment has a time-gain compensation (TGC) or
45
8 Ultrasound physics and technology

depth-gain compensation (DGC) control, to allow

for greater amplification of the weaker echoes return- Smooth
surface
ing from deeper within the body.
A variety of processes cause attenuation, but the
five main processes to be considered are:
1 absorption
2 reflection
3 scattering
4 refraction
5 divergence.

Absorption Fig. 8.1 · A large interface compared with the size

of the wavelength of the sound
This is the main factor causing attenuation of the
ultrasound beam. The higher the frequency of
the sound wave, the greater the amount of absorp- (such as organ boundaries (see Fig. 8.1)), some of
tion that will occur. the energy of the beam is reflected back in the form
Energy is transferred from the sound wave into of an echo (see Fig. 8.2), while the remainder of the
the medium through which it is traveling. beam carries on traveling forward through the
The rate of absorption depends on the absorp- tissue. This is known as specular reflection.
tion coefficient of the material through which it The amount of energy that is reflected depends
is traveling. Bone will have a much higher absorp- on the size of the acoustic impedance mismatch
tion coefficient than soft tissue. The absorption between the two tissue types. The greater the acous-
coefficient is proportional to the frequency. As an tic impedance mismatch, the greater the reflected
example, the absorption coefficient for a 7 MHz fre- component that occurs. At the interface between
quency wave is twice that of a 3.5 MHz frequency the liver and kidney, approximately 1% of the inci-
wave, e.g. a 3.5 MHz wave traveling through 1 cm dent beam will be reflected. At the interface between
of liver will have its intensity reduced by 50%, the liver and biliary calculi, almost 40% is reflected,
whereas a 7 MHz wave traveling through half this whereas at the interface between the liver and air in
distance (0.5 cm of liver) will have its intensity the bowel, 99.9% of the beam will be reflected. This,
reduced by the same amount. therefore, will result in very little information being
Some absorption will be due to the energy lost transmitted beyond air or calculi, due to the large
from the sound wave in overcoming the opposi- percentage of reflected sound. See Chapter 4 on
tion to its forward propagation. Other absorption Acoustic impedance.
will occur due to a transference of energy during The echoes reflected from large interfaces will
the compressive part of the sound wave cycle. only be returned to the transducer if the ultrasound
The majority of the lost energy will cause a rise
in temperature of the tissue through which the
sound is traveling. This heating effect is a potential Smooth
hazard when scanning biological tissue, although it surface
can be used to advantage, for example, by physio-
therapists when using ultrasound for treatment of
soft-tissue injuries.

Reflection
As a beam of ultrasound travels through tissue it
will encounter interfaces between different types
of tissue. Where these interfaces are large compared
with the size of the wavelength of the sound Fig 8.2 · Specular reflection from a smooth surface
46
 Ultrasound interactions and attenuation

beam is at 90
to the boundary. The angle of inci-

Rough
dence of the ultrasound beam will always equal the surface
angle of reflection (see Fig. 8.3). Any interfaces which
are not perpendicular to the beam will, therefore, not
be visualized during the scanning procedure,
because the reflected echoes will not be received by
the transducer.

Diffuse reflection
When the interface is rough and the undulations
are approximately one wavelength or less (see
Fig. 8.4) then sound is reflected in all directions.
This is known as diffuse reflection (see Fig. 8.5).
Fig 8.5 · Diffuse reflection

Reflected wave Scattering

Reflector When an interface is equivalent to one wavelength
in size, the reflected echoes are scattered in many
Angle of
reflection
directions (see Fig. 8.6). Because the wavelength
depends on the frequency of the sound (the higher
the frequency, the shorter the wavelength), more
scattering will be noted at higher frequencies.
Angle of Some of this scattered energy will return to the
incidence transducer and be recorded as echoes. Organ paren-
chyma information will largely be composed of
scattered energy (see Fig. 8.7). The majority, how-
ever, will be scattered non-uniformly in a variety
Incident wave of directions and not be recorded.

Fig. 8.3 · The angle of incidence and the angle of

reflection are equal

Rough
surface

Sound wave

Fig. 8.6 · Interfaces that are approximately one

Fig. 8.4 · A rough interface with undulations equal wavelength in size and where the reflected echoes
to approximately one wavelength are scattered in many directions

47
8 Ultrasound physics and technology

Velocity 1
Deviation of
ultrasound beam
Velocity 2
Fig. 8.7 · Image showing the effects of diffuse
reflection and scatter from the parenchyma of the
liver and specular reflection from the diaphragm
and renal boundary
Object’s true
position

When an interface is smaller than the wavelength, Position

the scatter is equal in all directions and is known as of image
Rayleigh scattering. Fig. 8.8 · How a refracted ultrasound beam causes
misregistration

Refraction
Snell’s law
If a beam of sound passes through an interface
between two tissues where the speed of sound is dif- This is a formula which gives the relationship
ferent, and if the angle of incidence is not perpen- between the angle of incidence and the angle of
dicular to the interface, then the path of the beam refraction when a beam of sound passes through
will be deviated or refracted (see Fig. 8.8). Both fac- an interface between two tissues where the speed
tors have to be present in order for refraction to of sound is different (see Fig. 8.9).
occur, therefore, with an oblique angle of incidence
between tissues of different acoustic impedances, sinyi c1
no refraction would occur if the speed of sound ¼
sinyr c2
were the same in both tissues.
yi ¼ angle of incidence
Deviations of the beam of up to 10% may occur,
yr ¼ angle of refraction
and this can lead to incorrect placement or misreg-
c1 and c2 ¼ speeds of sound in the two media
istration of displayed echoes (see Fig. 8.8). Some of
this misregistration will appear as obvious artifacts;
others may be more subtle and be wrongly inter-
Divergence
preted by the operator. Errors in measurements
can also result from this refraction of the beam. As a beam of ultrasound travels through tissue, it
The actual amount of misregistration depends on will diverge due to diffraction effects. This diver-
both the size of the angle of approach, and the gence will result in the same power spread over a
amount of difference in speed between the two larger area. The intensity (power/unit area) of the
tissues. beam will therefore be reduced.

48
 Ultrasound interactions and attenuation

Normal

Angle of
incidence Near field Far field

θi

C1
C2

θr
Fig. 8.10 · How an ultrasound beam diverges in the
far field
Angle of
refraction

Fig. 8.9 · The variables in the Snell’s law formula

In addition, the returning echo wave fronts will Divergence will be most notable distal to the
also diverge, causing a reduction in intensity with focal zone of a focused transducer or in the far
the greater the distance they travel. field of a non-focused transducer (see Fig. 8.10).

SUMMARY
· As a sound wave travels through a medium, it loses energy, and as a result, its intensity and amplitude decrease,
and it becomes attenuated
· Attenuation is proportional to the frequency of the sound wave and the distance that the wave travels
· The higher the frequency and the further the wave travels, the greater the attenuation
· In clinical imaging, the amount of expected attenuation should determine the frequency of the transducer that
is selected
· When imaging a deep structure, a large amount of attenuation would be expected, therefore, a lower frequency
transducer should be used
· Attenuation results from five main effects:
– Absorption
– Reflection
– Scattering
– Refraction
– Divergence

49
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 Artifacts
9
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 List the basic assumptions made by ultrasound

Assumptions made by ultrasound
equipment which gives rise to artifacts.
equipment 51
2 Describe the appearances of the more
Reverberation 52
common artifacts encountered during
Acoustic shadowing 53 ultrasound scanning.
Acoustic enhancement 54 3 Explain the causes of the commonly arising
artifacts.
Edge shadowing 55
Beam width artifact 56
Slice thickness artifact 56 An ultrasound artifact is a structure in an image
Side lobe artifact 58 which does not directly correlate with actual tissue
Mirror image artifact 59
being scanned. Artifacts assume different forms,
including:
Double image artifact 59 l structures in the image that are not actually

Equipment-generated artifacts 60 present

l objects that should be represented but are

missing from the image

l structures which are misregistered on the

image.
Where an operator is not aware of the presence of
artifacts, it is possible that pathology will not be
demonstrated and will therefore not be diagnosed
(false negative result), or that pathology will be diag-
nosed where it does not exist (false positive result).
Understanding the basic mechanisms behind
ultrasound artifacts, recognizing situations in
which they are likely to arise, and becoming famil-
iar with their appearance all help to eliminate
misdiagnoses that may otherwise occur.

ASSUMPTIONS MADE BY ULTRASOUND

......................................................
EQUIPMENT
Ultrasound machines have to make certain assump-
tions in order to operate. These are:

51
9 Ultrasound physics and technology

......................................................
l The speed of sound propagation is the same
REVERBERATION
in all tissue types (usually equipment
assumes this to be equal to 1540 m/s) This is the production of spurious (false) echoes
l The ultrasound beam travels in straight lines due to repeated reflections between two interfaces
l The time taken after emission of a pulse for with a high acoustic impedance mismatch. The
an echo to return to the transducer from an echo from the interface is received by the transducer
interface is directly related to the distance of and displayed on the image. Some of the energy in
the interface from the transducer the returned echo is reflected at the transducer face,
l Attenuation of sound in tissue is uniform and returns to the reflecting interface as if it was a
l All echoes detected by the transducer have weak transmitted pulse, returning as a second echo
arisen from the central axis of the beam (reverberation). As the time taken for the second
l An echo generated at an interface returns echo to arrive is twice that taken by the first echo,
directly in a straight line to the transducer the image will display it at twice the depth. This
without generating any secondary echoes sequence of reflection and transmission can occur
l The intensity or strength of the returning many times, with the third echo taking three times
echo is proportional to the density of the as long to return to the transducer and being dis-
reflector generating the echo. played at three times the depth, and so on. The
These assumptions are often incorrect and will reverberation echoes will be equally spaced because
give rise to appearances which do not correspond the time for each additional echo is a multiple of the
to actual anatomy or tissue in the scan plane. It time of return of the first echo. These reverberation
is these appearances that we term artifacts. echoes will be strong because of the high acoustic
Several possible artifactual appearances may mismatch (see Fig. 9.1).
occur: This artifact will often be seen:
l There may be areas incorrectly showing l at the skin–transducer interface when the

absence of echoes sound reverberates between the subcutane-

l Echoes may appear in areas which do not ous fat/muscle layer and the transducer (see
represent actual interfaces Figs 9.2 and 9.3)
l Separate structures may appear joined l behind bowel gas when the sound reverberates

l A single structure may appear as separate between the gas surface and the transducer
structures (also known as ringdown) (see Fig. 9.4).
l The brightness or textural appearance of The artifact can be differentiated from real echoes
echoes may not correlate with actual tissue due to the lack of breathing movement occurring.
structure
l Thin structures may appear thicker than

reality or vice versa.

There are a multitude of different artifacts which
may occur, but the more commonly occurring arti-
facts which will be discussed in this chapter are:
l reverberation

l acoustic shadowing

l acoustic enhancement

l edge shadowing

l beam width artifact

l slice thickness artifact

l side lobe artifacts

l mirror image

l double image Fig. 9.1 · Repeated reflections between two interfaces

l equipment-generated artifacts. cause reverberation of the displayed echoes

52
 Artifacts

To help to eliminate this artifact it may be

useful to:
l increase the amount of gel used

l use a stand-off pad (such as a commercially

produced gel pad or a bag of saline)

l reduce the gain

l move the position of the transducer.

Fig. 9.2 · Reverberation occurring at the

skin–transducer interface
......................................................
ACOUSTIC SHADOWING
This appears as an area of low amplitude echoes
(hypoechoic or anechoic) behind an area of strongly
attenuating tissue. It is caused by severe attenuation
of the beam at an interface, resulting in very little
sound being transmitted beyond (see Fig. 9.5). The
attenuation can be due to either absorption or reflec-
tion of the sound waves, or a combination of the two.
Acoustic shadowing will occur at interfaces with
a large acoustic mismatch such as:
l soft tissue and gas (where the degree of

attenuation will be due to reflection of

99.9% of the beam)
l soft tissue and bone or calculus (where the

attenuation is due to a combination of

approximately 40% reflection of the beam
and 60% absorption by the bone).
Fig. 9.3 · Reverberation arising at the skin–transducer
interface and appearing in the bladder
It is often possible to differentiate diagnostically
between structures such as gas in the duodenum
or calculi in a small contracted gallbladder, by
looking at the type of acoustic shadowing. Often
shadowing in this area can be ambiguous and
lead to an inaccurate diagnosis, but careful

Transducer

Gallstone

Acoustic
shadowing

Fig. 9.4 · Reverberation occurring between bowel

gas and transducer, appearing in the image distal Fig. 9.5 · Acoustic shadowing posterior to a strongly
to the bowel gas, and known as ringdown attenuating gallstone

53
9 Ultrasound physics and technology

......................................................
examination will reveal different types of sha-
ACOUSTIC ENHANCEMENT
dowing. If the shadowing contains reverberation
(ringdown) echoes, it is likely to be gas (see This artifact appears as a localized area of
Fig. 9.6a & b). If the shadowing is clear shadow- increased echo amplitude behind an area of low
ing, absent of any ringdown, it is likely to be a attenuation. On a scan it will appear as an area
calculus (see Fig. 9.7 a & b). of increased brightness, and can commonly be

Fig. 9.6a & b · Acoustic shadowing occurring in the region of the gallbladder (suggesting possible biliary calculi),
but as it contains ringdown, it is more likely to be caused by gas in the adjacent bowel

Fig. 9.7a & b · Acoustic shadowing posterior to biliary calculi due to a combination of reflection and absorption
54
 Artifacts

seen distal to fluid-filled structures such as the uri-

nary bladder, the gallbladder, or a cyst.
The artifact arises due to the application of the
time-gain compensation (TGC) to areas of low
attenuating structures such as fluid. It is caused by
the low level of attenuation of the beam as it passes
through fluid relative to the greater attenuation of
the beam in the adjacent more solid tissue (see
Fig. 9.8). As the echoes pass beyond the area, they
will be of higher amplitude than the surrounding tis-
sue because they have been amplified unnecessarily.
The high amplitude brightness therefore does not
relate to any inherent scattering or reflectivity proper-
ties of the tissue, but arises because the equipment
assumes a uniform rate of attenuation across the
entire image (see Fig. 9.9).

Fig. 9.10 · Acoustic enhancement posterior to a soft

tissue mass
Transducer

This artifact can often be a useful diagnostic aid,

Cyst particularly when scanning a soft-tissue mass or cyst
containing low-level echoes. These echoes may often
cause the structure to disappear in the image as it
blends into the surrounding echo pattern. The obser-
Acoustic vant operator will often notice the echo enhance-
enhancement
ment, resulting in a closer examination of the area
above this, and the mass or cyst will then be deli-
Fig. 9.8 · Acoustic enhancement posterior to a low neated (see Fig. 9.10).
attenuating cyst

......................................................
EDGE SHADOWING
A combination of refraction and reflection occur-
ring at the edges of rounded structures (and when
the speed of sound is different from that in sur-
rounding tissue) will result in an edge shadowing
artifact.
Edge shadowing arises due to refraction of
the beam caused by both the curvature of the
rounded edges and the difference in speed of
the two materials. When the ultrasound beam
reaches the rounded edge of a structure, reflection
will occur, with the angle of incidence equal to
the angle of reflection. The outer part of the beam
will be totally reflected, but the remainder of the
beam passes through the rounded structure and
is refracted (deviated from its original path) (see
Fig. 9.9 · Acoustic enhancement posterior to a cyst Fig. 9.11). This combination of reflection and
55
9 Ultrasound physics and technology

Transducer

Reflected
beam

Cyst

Refracted
Edge beam
shadowing
Fig. 9.13 · Edge shadowing posterior to a soft-tissue
mass

Fig. 9.11 · Edge shadowing

......................................................
BEAM WIDTH ARTIFACT
All the echoes returning to the transducer will have
arisen from across the full width of the beam, which
refraction of the beam at the edge of a rounded can vary by several millimeters. As the beam sweeps
structure results in a thin strip of tissue behind through the patient, a point reflector will generate
the edge not being insonated and causes a an echo for as long as it remains in the beam, and
shadow. These shadows are narrow and occur the reflector will be represented as a line in the dis-
directly distal to the margins of the rounded play rather than a dot. The length of the line will
structure, such as either a cyst (see Fig. 9.12) or therefore represent the beam width at that depth.
a soft-tissue mass (see Fig. 9.13). The shadowing This artifact can be demonstrated by scanning a
should normally be readily identified as an arti- point reflector in a phantom, where the display will
fact, however it is possible that it may be falsely clearly portray this as a line (Fig. 9.14).
diagnosed as areas of calcification within an During routine scanning, the artifact can be seen
organ. when spurious echoes are displayed in an echo-free
area, for example when reflections from bowel are
generated by the edge of the beam and displayed
inside the sagittal view of the urinary bladder, where
the center of the beam is (see Figs 9.15 & 9.16).
Correct positioning of the focal zone will help to
reduce this artifact. The focal zone is controlled by
electronically narrowing the beam (see Chapter 5
on The ultrasound beam).

......................................................
SLICE THICKNESS ARTIFACT
These occur due to the thickness of the beam, and
are similar to beam width artifacts (see Chapter 5
on The ultrasound beam). However, they occur at
90 to the scan plane (see Fig. 9.17), with echoes
from interfaces in front of and behind the assumed
Fig. 9.12 · Edge shadowing posterior to a cyst plane of origin appearing in the display.
56
 Artifacts

Transducer

Bowel
Echoes from bowel
displayed within the
bladder

Fig. 9.15 · Beam width artifact

Fig. 9.14 · Scan of a phantom demonstrating that

the point reflectors can be seen as points in the
center of the image where the focal zone is set (and
the beam is therefore narrowest), but the same points
appear as lines where they lie outside the focal zone
(and the beam is wider)

It is assumed that the echoes detected by the Fig. 9.16 · Beam width artifact in a sagittal view of
transducer are from a very thin slice of tissue. the bladder
However, the reality is that this slice is actually
composed of several slices of information and
therefore echoes from interfaces on either side of arising from within the bladder (see Fig. 9.19).
the intended thin slice will be included in the dis- Although the appearance of this artifact is similar
played image (see Fig. 9.18). Increasing the slice to the beam width artifact, the differentiating fac-
thickness will increase the number of artifactual tor is that the reflector causing the slice thickness
echoes in the display. artifact will not be seen on the display.
These artifacts will typically be seen in trans- This artifact is a result of inherent characteristics
verse views of the urinary bladder when structures of the transducer, and apart from trying a different
adjacent to the slice through the bladder being transducer, cannot be eliminated. New technol-
scanned will be incorporated into the image. ogy, however, is continuously resulting in nar-
These echoes are then displayed as if they were rower slice thicknesses.
57
9 Ultrasound physics and technology

Transducer
Transducer

Side lobes

Main beam

Slice Beam width

thickness Fig. 9.20 · Side lobes
Fig. 9.17 · Beam width and slice thickness
transducer to have arisen from the central axis of
the main lobe (see Chapter 5 on The ultrasound
beam). Side lobe echoes will therefore be misregis-
1 + 2 + 3 = tered in the display. Because ultrasound beams are
three-dimensional, side lobes exist not only in the
scan plane but also in the entire 360 around the
1 1+2+3 beam. The echoes generated by the side lobes are usu-
2
3 = super- ally much lower in amplitude than the main beam
imposed
and will therefore often not be seen, unless the ech-
oes are returning from a strong reflector such as gas.
Fig. 9.18 · Each image is composed of several slices This artifact can often be seen in areas such as the
of information added together
urinary bladder where the side lobes detect echoes
from adjacent bowel and the equipment registers
these echoes as if they have arisen from within the
bladder. They may also arise within a cyst, where adja-
cent structures are portrayed as if arising from within
the cyst (see Fig. 9.21). These appearances can give
rise to a false diagnosis of septations within a cyst.

Fig. 9.19 · Slice thickness artifact in a transverse view

of the bladder

......................................................
SIDE LOBE ARTIFACT
The energy within the ultrasound beam exists as
several side lobes radiating at a number of angles
from a central lobe (see Fig. 9.20). Echoes are gener- Fig. 9.21 · Artifact in a cyst caused by information
ated by these side lobes in addition to the main lobe, obtained by the side lobes and leading to possible
but all the returning echoes are assumed by the misdiagnosis of a septated cyst

58
 Artifacts

......................................................
MIRROR IMAGE ARTIFACT
These artifacts result in a mirror image of a structure
occurring in an ultrasound display. They arise due
to specular reflection of the beam at a large smooth
interface. An area close to a specular reflector will
be imaged twice, once by the original ultrasound
beam and once by the beam after it has reflected
off the specular reflector. Echoes return along the
same path from the reflecting interface, back to
the transducer. Because the equipment assumes all
echoes arise from a straight beam, the reflected ech-
oes are displayed in a line as if originating from
below the specular reflecting surface (see Fig. 9.22).
Fig. 9.23 · Mirror image artifact of the bladder
Mirror image artifacts are most commonly seen imitating a cyst in the pelvis
where there is a large acoustic mismatch, such as a
fluid–air interface. Typically this artifact can occur
during the scanning of a full urinary bladder,
when air in the rectum behind the bladder acts
as a specular reflector and a mirror image of the
bladder is displayed posteriorly. It will then have
the appearance of a large cyst behind the bladder
(see Fig. 9.23). It can also be seen when scanning
the liver, and the diaphragm acts as a specular
reflector. In this case the liver parenchyma is dis-
played not only below the diaphragm but also
above it (see Fig. 9.24). When trying to determine
whether these appearances represent pathology or
artifact, it is important to recognize whether the
echoes have the same appearance as the organ
from which they have arisen.
Fig. 9.24 · Mirror image artifact of the liver appearing
above the diaphragm (From Bates 1999, with
permission of Churchill Livingstone.)

......................................................
DOUBLE IMAGE ARTIFACT
This artifact is caused by refraction of the beam
and may occur in areas such as the rectus abdomi-
Urinary bladder nis muscle on the anterior abdominal wall. In the
transverse plane the edges of the muscle act as a
lens and cause the ultrasound beam to be refracted
Perpendicular reflection
of the beam (i.e. deviated from its original path) and this
causes a single structure to be interrogated by
two separate refracted beams (see Fig. 9.25). Two
sets of echoes will therefore be returned and these
Mirror image
of bladder will cause display of two structures in the image.
This results in, for example, two images of the
transverse aorta side by side in the abdomen (see
Fig. 9.22 · Mirror image artifact Fig. 9.26). Alternatively, a single gestation sac can
59
9 Ultrasound physics and technology

Rectus abdominis
muscle

Actual beam refracted

and separated into two beams

Equipment interprets
information from two beams
as if arising from two separate
structures
Fig. 9.27 · Too much gain causing artifactual echoes
Fig. 9.25 · Double image artifact caused by refraction
of the beam

Fig. 9.28 · Incorrect use of TGC causing artifactual

Fig. 9.26 · Double image artifact of the aorta echoes

be mirrored and appear as two gestation sacs side can result in echoes being recorded as too bright
by side, leading to the erroneous diagnosis of a or too dark. Care must be taken when setting these
twin pregnancy. In order to establish whether controls, to ensure an even brightness throughout
these echoes are genuine, it is necessary to move the image. If too much gain is applied then the
the transducer slightly to one side to avoid the electronic noise, inherent in all systems, will also
junction of the rectus abdominis muscles. be amplified. This has the appearance of a fine
overlay of low-level echoes in the image and will

......................................................
cause deterioration of the quality of the image,
EQUIPMENT-GENERATED ARTIFACTS
reducing the ability of the operator to correctly
Incorrect use of the equipment controls can lead to interpret. If too little gain is applied, this can lead
artifacts appearing. Misuse of controls such as the to loss of relevant information, and incorrect diag-
gain (see Fig. 9.27) or TGC (see Figs 9.28 & 9.29) nosis may occur.
60
 Artifacts

Fig. 9.29 · Incorrect use of TGC causing artifactual Fig. 9.30 · The image has too much contrast resulting
appearances in the loss of subtle information

If the dynamic range control is incorrectly set, important to ensure that the frame rate is capable
this can lead to an image which has too much of recording a moving structure at the correct speed.
contrast, and result in the loss of subtle echo infor- Use of multiple focal zones can give rise to a
mation (see Fig. 9.30). prominent banding effect within the image. These
Blurring of a moving image can occur if the frame are usually identifiable as being of electronic origin
rate is too low or if the persistence is too high. It is due to the well-defined margin of the bands.

SUMMARY
· An ultrasound artifact is a structure in an image which does not directly correlate with actual tissue or structures
· Artifacts occur due to false assumptions made by the equipment
· Failure to recognize artifacts can lead to misdiagnosis
· Many different artifacts occur during routine ultrasound scanning but the more common ones include:
– Reverberation
– Acoustic shadowing
– Acoustic enhancement
– Edge shadowing
– Beam width artifact
– Slice thickness artifact
– Side lobe artifact
– Mirror image
– Double image artifact
– Equipment-generated artifacts

Reference
Bates JA 1999 Abdominal ultrasound, 2nd edn. Churchill
Livingstone, Edinburgh.

61
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 Instrumentation and controls
10
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 List the primary components of an ultrasound

Introduction 63 machine.
Components of a typical ultrasound 2 Understand the basic function of each
machine 63 component.
System configuration – use of presets 66 3 Identify the primary operator-dependent
Function of ultrasound controls 67 controls.

Measurements 71 4 Explain how a number of key controls

influence image quality.

......................................................
INTRODUCTION
A diagnostic ultrasound machine consists of many
components, each of which has a separate operation
to perform. This starts with transmitting and receiv-
ing ultrasound signals which are then processed to
form the images that we see on screen. The internal
components that make up a typical ultrasound
machine are listed below. Figure 10.1 illustrates the
architecture of the components in a block diagram.
l Transducer

l Pulser

l Beam former

l Receiver

l Processor

l Display

l Digital storage

l Hard copy printer devices.

COMPONENTS OF A TYPICAL
......................................................
ULTRASOUND MACHINE
The Transducer
Diagnostic transducers are made from piezoelec-
tric materials (see chapter on Transducers) and

63
10 Ultrasound physics and technology

Pulser
(transmitter)

Receiver

Beam Display
former

Processor

Transducer

Hard Soft
copy copy
Patient
Film/paper Digital
storage storage
Fig. 10.1 · A block diagram of an ultrasound imaging machine

are able to convert electrical energy into ultra- Beam Former

sound energy and vice versa. As a consequence
The beam former controls the shape and direction
of this they can act as a transmitter and receiver
of the ultrasound beam and the scanning patterns
of ultrasound. They are able to produce beams
used to form the images that we see. This enables
which can be directed in various ways which are
the operator to have indirect control of:
controlled by the ultrasound machine to improve
l depth
image quality.
l focus

l sector width

l zoom.
The Pulser
The pulser produces the electric voltage that drives
the transducer. This driving voltage governs the
Receiver
output power of the ultrasound machine and can The job of the receiver is to combat attenuation,
be adjusted by the operator through the power or i.e. the energy lost from the beam as it propagates
output control. Changes in the applied voltage through soft tissue. As a consequence of attenua-
to the transducer changes the strength and inten- tion the returning echo amplitudes and intensities
sity of the ultrasound beam, and affects the overall are decreased. Most of the energy is lost from the
brightness of the B-mode image. The greater the beam through absorption which is mainly con-
applied voltage, the stronger the ultrasound pulse verted into heat. The receiver applies amplification
and the higher the pulse intensity. Figure 10.2 to the returning echoes to make them stronger and
illustrates the effect that increasing the applied to enable them to be visualized. The ultrasound
voltage has on the B-mode image. Increasing the machine can compensate for the effects of attenu-
applied voltage to the transducer increases the ation by amplifying the received signals in two
ultrasound pulse intensity, resulting in an increase ways, using the overall gain and the time-gain
in the overall brightness of the image. compensation (TGC) controls.
64
 Instrumentation and controls

Voltage

Voltage

Voltage

Fig. 10.2 · Increasing the applied voltage to the transducer increases the pulse intensity and output power, resulting
in brighter images

Processor picks up the amplified signals from the receiver

and carries out operations such as filtering, ampli-
The processor can be divided into two individual
tude detection, and signal compression.
parts, each having very different tasks to fulfil,
Filtering cleans up the signal, removing unwanted
and consists of:
noise, and also controls the signal bandwidth (see
l a signal processor – converts echo voltages to
chapter on Transducers). Amplitude detection per-
video signals
forms a process of demodulation which means it
l an image processor – formats the many scan
converts the received signal voltages into video form,
line data into image form.
retaining the amplitude information required for B-
A simple block diagram of the signal processor is
mode imaging. Compression controls the dynamic
illustrated in Figure 10.3. The signal processor
range of the B-mode image (the number of shades
of gray displayed in the image).
Signal processor Once the signals have passed through the signal
From Into image processor they are fed into the image processor.
receiver processor
A block diagram of the image processor is illu-
strated in Figure 10.4. The image processor per-
forms operations such as scan conversion which
Amplitude
Filter Compression reformats the scan line data into two-dimensional
detection
images, i.e. either linear or sector form. The ability
Function Function Function of the scan converter to rapidly process the
Filtering Demodulation Controls dynamic thousands of scan line data received every second
– noise reduction – converts echo range
voltages to video – range from the transducer enables real-time dynamic
form of echo levels ultrasound imaging to be performed.
– retains processed There is a range of processing performed on the
amplitude data image data prior to and following storage into
Fig. 10.3 · Block diagram of the signal processor memory before they are finally sent to the display.
outlining the key functions of each component Functions such as edge enhancement are known as
65
10 Ultrasound physics and technology

Image processor

From signal
processor

Scan
converter
Formats scan line data Display
into image form

Pre- Image Post-

processing memory processor

Processing of Stores sequential Functions performed

image data before image frames on a frozen image
stored in memory

– edge enhancement – cineloop – read zoom

– choice of gray scale
Fig. 10.4 · A block diagram of the image processor outlining the key functions of each component

pre-processing functions because they are per- Hard Copy and Soft Copy Storage
formed before being stored.
The images displayed on screen can be sent out to
Image memory stores a number of sequentially
an external hard copy device such as radiographic
acquired and processed static image frames every
film or thermal paper printers. Alternatively, the
second which are rapidly sent to the display to
images, which can also consist of short cineloop
provide dynamic real-time ultrasound. This pro-
review video clips, can be digitally stored on the
cess can be interrupted by activating the freeze
machine’s hard disc or alternatively burnt to CD
control which stops any further acquisition and
or DVD. Many ultrasound departments are linked
processing of data from the transducer. In freeze
into a picture archiving and communications
mode only one static image in the memory is dis-
system, more commonly known as PACS. This
played. The numerous frames of image data held
enables images such as X-rays and ultrasound
and stored can be reviewed in turn using the
scans to be stored electronically and viewed on
machine’s cineloop control function.
any PACS display monitor around the hospital at
the touch of a button.

The Display
Once the images have been processed they can
SYSTEM CONFIGURATION – USE OF
......................................................
either be displayed on a traditional cathode ray
PRESETS
tube which is used in conventional televisions or
be presented on a computer monitor or a flat Many ultrasound machines provide the operator
panel screen. There are only two controls that with a range of stored preconfigured control set-
can be adjusted on most displays, which are tings known as presets. Before starting any investi-
brightness and contrast. These can be set by the gation the operator should select and initialize the
operator according to individual preference or specific preset which has been configured to auto-
ambient room lighting conditions. matically select various control parameters such as
66
 Instrumentation and controls

gain, depth, power, focus, etc., together with the However, increasing the output power causes
most appropriate processing functions to optimize the patient to be exposed to more ultrasound
the image performance of the ultrasound system. energy which could increase the risk of causing
There are a number of different presets which can any possible harmful effects that are more likely
be selected by the operator for each type of clinical to affect sensitive tissues such as rapidly develop-
examination whether it be, for example, liver, pel- ing cells found in embryo, fetus, and neonate.
vis, obstetric, abdominal, or vascular. The ultra- The alternative and safer option rather than
sound system can also store additional presets for increasing the output power is to amplify the
different users; each stored preset can be selected received signals using the machine’s gain and/or
with a single keystroke. TGC controls. This minimizes exposure while
Despite the inclusion of system configured pre- improving the image quality.
sets in most current ultrasound equipment it is
important for the operator to have an understand- Overall gain
ing of the function of each manual control,
Overall receiver gain provides uniform amplifica-
because many of these preset modes will require
tion of all the received signals regardless of depth,
further manual manipulation throughout the
and affects the brightness of the overall image. The
scanning procedure. Patient body habitus will vary
operation of the gain is to compensate for the loss
significantly, resulting in a requirement for
of energy through attenuation as the beam propa-
changes to the equipment controls throughout
gates through the patient.
the examination.
There is no ‘absolute’ or ‘correct’ setting. The
gain will require adjustments throughout the
examination and will vary with each individual
......................................................
FUNCTION OF ULTRASOUND CONTROLS patient according to the organ or vessel being
Image Controls scanned or to the body habitus of the patient. This
will involve increasing the level of the gain for
A large number of controls are available to be used scanning deeper structures and decreasing it when
on most ultrasound equipment but the more scanning superficial structures. However, there is a
important and most frequently used controls are limit to how much the received signals can be
discussed below. amplified which is governed by the level of noise
within the signal.
Output power Amplifying the signal strength also amplifies
the level of background noise within the signal,
The output power of an ultrasound machine is
which becomes more significant as the levels of
determined by the pulser which produces the elec-
amplification increase to the point where the level
tric voltage that drives the transducer. The output
of the background noise in the signal is greater
power is automatically set for each preset mode
than that of the received signal. The depth at
and can be manually manipulated through the
which this occurs is known as the penetration
power or output control. Ultrasound machines’
depth. When background noise is visualized this
output powers are limited, and should not exceed
is the point to stop increasing the gain and to
720 mWcm 2 specifically for safety reasons (see
increase the output power if safe to do so.
chapter on Ultrasound safety).
The effect of increasing the output is to increase
Time-gain compensation (TGC)
the amplitude and intensity of emitted ultrasound
pulses which in turn increases the size of the return- The TGC is similar to the overall gain inasmuch
ing signals. Improving the signal strength of return- as they both compensate for the effects of attenua-
ing echoes improves the clarity and detail of tion. Attenuation causes weaker signals to be
structures within the B-mode image. The effect of received from structures that lie deeper than
increasing the output power is demonstrated in those which lie closer to the face of the trans-
Figure 10.2 which shows that the higher the output ducer. The TGC can compensate for this loss of
power, the brighter the overall B-mode image. signal strength so that equal amplitudes can be
67
10 Ultrasound physics and technology

Fig. 10.5 · Examples of TGC slider controls

displayed from all depths within the scan plane signals of similar amplitude and displayed bright-
as the same brightness on the image. This is ness over depth.
simply achieved by applying a variable gain to The processes involved with TGC of received
the received signals so that signals returning later signals are illustrated in Figure 10.6.
are amplified more than those previously received.
The TGC does this through a number of horizontal
Depth
slider controls as shown in Figure 10.5. Their rela-
tive position governs the amount of gain applied The depth control changes the maximum scanning
to the received signals from various depths within range viewed on screen. The ultrasound machine
the scan plane. The net result produces received determines depth indirectly by measuring the time

A. Transducer receives returning

echoes from different depths (times)
from similar boundaries.

B. Attenuation causes weaker signals

Amplitude

to be received from boundaries that lie

deeper than those which lie closer to
the transducer.
Time or / depth
C. To compensate for this effect a
Gain

variable gain is applied which

increases with the time that the signals
are received.
Time or / depth

D. The TGC slider controls are

adjusted by applying sloping of the
TGC throughout the image.

E. The net result produces received

signals with similar amplitude and
displayed brightness

Fig. 10.6 · Illustrating the processes involved with TGC of received signals (After Thrush & Hartshorne 2005.)
68
 Instrumentation and controls

it takes for a pulse to return. The system has to wait The number of focal zones is related to the
to receive all the returning echoes along each scan frame rate and is illustrated in the example below:
line for a selected depth before sending another.
As the depth control is increased the time it takes Example
for a pulse to return to the transducer also Consider a B-mode image which is made up of 100
scan lines of data. With 100 lines per image:
increases. This time factor imposes an upper limit
to the time interval between consecutive transmit Using 1 focal zone 40 fps can be achieved
pulses known as the pulse repetition frequency 2 focal zones 20 fps
(PRF). Changes in the depth changes the maximum 3 focal zones 10 fps
pulse repetition rate which affects the frame rate. 4 focal zones 2 fps
Increasing the depth decreases the system’s PRF
Doubling the number of focal zones halves the
which decreases the number of image frames that frame rate
can be displayed per second (fps).
Freeze and cineloop
Focus Activating the freeze button stops any further acqui-
The focus determines the depth at which the ultra- sition and processing of data from the transducer.
sound beam is focused and creates the best possi- Once frozen the ultrasound machine displays the
ble resolution at that depth. last acquired image which is held in image memory.
The focal position is usually displayed by a sym- Image memory is able to store many frames of
bol or vertical bar or bracket alongside the display image data which can be individually reviewed in
of the B-mode image. The focal zone should be turn using the cineloop control function. The actual
positioned at or just below the level of interest number of stored frames in the image memory will
within the B-mode image. The operator is able to vary according to the frame rate being used.
activate more than one focal zone, sometimes as
Sector width
many as five, however for each additional focal
zone another pulse must be sent along the same The sector width, also referred to as the sector
scan line. As a consequence of this, the number of angle, is important in determining the frame rate
frames of image data per second (fps) is reduced, at a given depth. The size of the sector width or
resulting in a slower frame rate and the images angle can be reduced by the operator and is as illu-
appearing disjointed. strated in Figure 10.7.

Fig. 10.7 · Illustrating sector width. a) B-mode image for a given depth, sector width and line density determines
the frame rate. b) Image with a reduced sector width

69
10 Ultrasound physics and technology

B-mode images are made up of a number of adja- news print very close up or using the digital zoom
cent scan lines; there can be many hundreds of scan facility on modern digital cameras.
lines used to form one image and the number of Real zoom, also known as write zoom, increases
scan lines used is known as the line density. A sector the ultrasound information content within the
width for a given depth and line density determines image, i.e. improves image resolution by increasing
the frame rate and is seen in Figure 10.7a. the scan line density and the number of pixels per
Reducing the sector width as seen in Figure 10.7b square centimeter. The effect is similar to using a
can bring about improvements to the overall frame camera’s optical zoom function.
rates and/or image resolution. On some machines it can be difficult to deter-
At a given depth, reducing the sector width means mine if the zoom facility is either read or write.
that fewer scan lines are required to form an image.
This reduces the time needed to build up an image, Dynamic range/log compression
resulting in higher frame rates. These high frame Dynamic range refers to the way that the gray scale
rates are required when imaging the heart, for exam- information is compressed into a usable range for
ple, and this technique of improving the overall display on the monitor. A broader or wide
frame rate is used especially when scanning the fetal dynamic range yields more shades of gray, while
heart in obstetrics. a smaller or narrow dynamic range results in a
Alternatively, reducing the sector width can more black and white appearance of the image.
bring about improvements to image resolution if Figure 10.8 illustrates the effect that increasing
the number of scan lines within this reduced sec- the dynamic range has on the ultrasound image.
tor is maintained, i.e. using thinner scan lines. Since the range of signal amplitudes which are
This brings about no improvements to frame rates detected is so large, a decibel scale is used (dB).
(they remain unchanged), but the increased line The dynamic range in decibels (dB) refers to the
density increases the spatial resolution, namely amount that the signal is compressed and expressed
lateral resolution. as the ratio of the largest to the smallest signal that
The benefits of reducing the sector width are can be visualized (white and black respectively).
summarized in Table 10.1. For example, 60 dB represents a ratio of
1 000 000:1. The displayed dynamic range will
Zoom
affect the echo/gray scale assignment. A dynamic
If the region within the B-mode image is small or range of 40 dB (10 000:1 ratio) gives a highly con-
very deep the operator can use the zoom control trasted image (see Fig. 10.8) that may be better for
to magnify an area of interest on the screen. The visualizing the walls of vessels, for example. Here,
machine often allows the operator to adjust the we are not interested in differentiating between a
size and position of the region of interest. There wide range of gray levels as blood appears black
are two forms of zoom, read zoom and write and vessel walls appear bright white. A dynamic
zoom. range of 60 dB gives a softer image that may prove
Read zoom simply magnifies the image, bring- better for visualizing subtle differences within and
ing about no improvements to the quality of the between tissues, for example when scanning the
image. Using read zoom is similar to looking at liver as illustrated in Figure 10.8.

BENEFIT RESULT

Reducing the size of the sector width – increases scan line density – better detail
– more scan lines over the same area – increased image resolution
– fewer scan lines to process – increased temporal resolution
– increases frame rate

Table 10.1 Summarizing the benefits brought about by reducing the sector width
70
 Instrumentation and controls

Fig. 10.8 · Demonstrating the effect that increasing the dynamic range has on the overall ultrasound image

......................................................
for delivery. Ultrasound machines are able to take
MEASUREMENTS
a variety of measurements from frozen static B-
Measurement of key parameters within an ultra- mode images which include:
sound image is an essential part of interpreting l linear

ultrasound scans and aids with differentiating nor- l circumference

mal anatomy from pathology, monitoring fetal l area

growth patterns, and are used to estimate due dates l volume.

SUMMARY
· A diagnostic ultrasound machine consists of many components which generate, process and display the
received ultrasound signals
· Ultrasound machines have a large number of controls
· Each control influences image quality
· It is important for the operator to have an understanding of the function of each manual control in order to use
them correctly
· Most ultrasound machines provide the operator with a range of preconfigured control settings known as presets
· A number of measurements can be taken with ultrasound equipment and form an essential part of interpreting
ultrasound scans and differentiating normal anatomy from pathology

71
10 Ultrasound physics and technology

APPENDIX

EXERCISES TO IMPROVE YOUR UNDERSTANDING OF EQUIPMENT CONTROLS

The aim of these simple exercises is to become familiar with a number of B-mode imaging controls
PRESETS
4 Select a type of examination (carotid, obstetrics, abdominal, cardiac, etc.)
4 Make a note of the B-mode settings on the display and observe what alters as you change to different presets
4 Select a preset and choose an appropriate transducer. Use either a test object/phantom or willing
volunteer to obtain an ultrasound image
GAIN
4 Notice what happens to the image if the gain control is altered
TGC
4 Notice what happens to the image if the TGC slider controls are altered
DEPTH
4 When you alter the depth control, do any other parameters displayed on the monitor change? (Pay
close attention to the frame rate)
FOCUS
4 What happens to the image when you move the focal zone up or down?
4 What happens to the image if you select more than one focal zone?
4 What other parameters displayed on the monitor change when you use more than one focal zone?
SECTOR WIDTH
4 What parameters displayed on the monitor change when you reduce the sector width?
DYNAMIC RANGE
4 What happens to the image when you change the dynamic range?
CINELOOP
4 How many images can you review when you use the cineloop function?
4 How is this related to the frame rate?

Reference
Thrush A, Hartshorne T 2005 Peripheral vascular ultrasound: how,
why and when, Churchill Livingstone, Edinburgh, Fig. 2.11.

72
 Physical principles of Doppler
ultrasound
11
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 Outline the basic principles of the Doppler

Introduction 73
effect and how it is applied in medical
The Doppler principle 74 ultrasound.
The Doppler effect applied to 2 Discuss the significance of the angle of the
diagnostic ultrasound 75 Doppler beam to obtain reliable Doppler
signals.
The Doppler equation 76
3 Be aware of the relationship between blood
Types of Doppler instrumentation flow velocity (V) and the Doppler shifted
in diagnostic imaging 78 signals (F d ).
Doppler artifacts 88 4 List the types of Doppler ultrasound
instruments used in diagnostic ultrasound.
5 Describe continuous wave, color flow imaging,
and spectral Doppler instruments.
6 Identify typical Doppler artifacts.

......................................................
INTRODUCTION
This chapter provides the basic introduction to the
physical principles and application of Doppler
ultrasound in practice. The application of Doppler
in ultrasound was first introduced in the 1980s
and since then this technique has expanded in all
specialist fields of practical ultrasonography.
A Doppler ultrasound is a non-invasive test that
can be used to investigate movement and par-
ticularly evaluate blood flow in arteries and veins.
It can also be used to provide information regard-
ing the perfusion of blood flow in an organ or
within an area of interest. A more recent applica-
tion is the investigation of tissue wall motion
when evaluating the heart (see Chapter 14 on
New technology).

73
11 Ultrasound physics and technology

Doppler ultrasound can be used to diagnose the Doppler effect and applies to sound waves as
many conditions, including: well as light waves.
l heart valve defects and congenital heart

disease
l a blocked artery (arterial occlusion)
The Doppler Effect
l narrowing (stenosis) of an artery An everyday example which demonstrates the
l blood clots (deep vein thrombosis) Doppler effect is highlighted in Figure 11.1. We
l varicose veins (venous insufficiency) are all aware that the pitch of an ambulance siren
l arteriovenous malformations changes as we stop and listen to it as it drives by.
l movement of the cardiac wall. The frequency that reaches you is higher as the
ambulance approaches and lower as the ambu-
lance passes by. This is a consequence of the
......................................................
THE DOPPLER PRINCIPLE
Doppler effect.
The Doppler principle is named after the mathe- What is happening is that the sound waves are
matician and physicist Christian Johann Doppler compressed when an object producing sound is
who first described this effect in 1842 by studying moving in the same direction as the waves. The
light from stars. He demonstrated that the colored listener (observer) therefore receives shorter wave-
appearance of moving stars was caused by their lengths. However, when the source of sound has
motion relative to the earth. This relative motion passed the listener, the waves are now moving in
resulted in either a red shift or blue shift in the the opposite direction (away from the listener),
light’s frequency. This shift in observed frequen- the wavelength becomes longer and the listener
cies of waves from moving sources is known as therefore hears a change in frequency.

Approaching ambulance As ambulance passes by

Observer hears siren with Observer hears the frequency

a high frequency of the siren become lower
Fig. 11.1 · The consequence of the Doppler effect on the relative emitted frequency of an ambulance siren as it
drives by. The frequency of the approaching ambulance siren appears higher compared to the frequency of the
siren as the ambulance passes by which appears lower
74
 Physical principles of Doppler ultrasound

This Doppler effect is utilized in ultrasound A

applications to detect blood flow by analyzing
the relative frequency shifts of the received echoes
brought about by the movement of red blood
cells.
Ft = transmitted frequency
Fr = received frequency
Fr > Ft
THE DOPPLER EFFECT APPLIED TO Doppler shifted signal Fd = Fr - Ft Ft
......................................................
DIAGNOSTIC ULTRASOUND Positive Doppler shift
Fr
The Doppler effect in diagnostic imaging can be
used to study blood flow, for example, and pro-
vides the operator with three pieces of information
to determine:
l Presence or absence of flow
Blood flow
l Direction of blood flow

l Velocity of blood flow.

B
The transducer acts as both a transmitter and
receiver of Doppler ultrasound. When using
Doppler to investigate blood flow in the body,
the returning backscattered echoes from blood
are detected by the transducer. These backscattered
signals (Fr) are then processed by the machine to Ft = transmitted frequency
detect any frequency shifts by comparing these Fr = received frequency
Ft F r < Ft
signals to the transmitted Doppler signals (Ft).
Doppler shifted signal Fd = Fr - Ft
The frequency shift detected will depend on two Negative Doppler shift
factors, namely the magnitude and direction of Fr
blood flow (see Fig. 11.2).
Let us consider a simple arrangement as seen
in Figure 11.3. The transducer transmits a Doppler
signal with frequency Ft. The transmitted Doppler Blood flow
signal interrogates a blood vessel and the trans-
ducer receives the backscattered signals from the
red blood cells within the vessel at a frequency Fig. 11.3 · Demonstrating the resulting Doppler shifted
signals for a) blood flow moving towards the transducer;
b) blood flow moving away from the transducer

Fr. The Doppler frequency shift (Fd) can be calcu-

Ft = transmitted Doppler signal
lated by subtracting the transmitted signal Ft from
Ft the received signal Fr.
Fr = received Doppler signal
Fr Blood flow moving towards the transducer
produces positive Doppler shifted signals and
conversely blood flow moving away from the
Backscattered
signals from red transducer produces negative Doppler shifted
blood cells signals. Figure 11.3 illustrates the change in the
received backscattered signals and the resulting
Fig. 11.2 · An ultrasound transducer interrogating a Doppler shifts for blood moving towards and
blood vessel. Transmitting a Doppler signal with frequency
Ft and receiving the backscattered signals from the red
away from the transducer.
blood cells within the vessel at a frequency Fr In Figure 11.3a the relative direction of the
blood flow with respect to the Doppler beam is
75
11 Ultrasound physics and technology

towards the transducer. In this arrangement blood Relationship between Doppler Shifted
flow moving towards the transducer produces Signal (Fd) and Blood Flow Velocity (V)
received signals (Fr) which have a higher fre-
The Doppler equation (Equation 1) demonstrates
quency than the transmitted beam (Ft). The Dopp-
that there is a relationship between the Doppler
ler shifted signal (Fd) can be calculated by
shifted signal (Fd) and the blood flow velocity
subtracting Ft from Fr and produces a positive
(V). The Doppler shifted signal (Fd) is directly pro-
Doppler shifted signal.
portional to the blood flow velocity (V), which
Conversely, Figure 11.3b illustrates blood flow
means greater flow velocities create larger Doppler
which is moving away from the Doppler beam
shifted signals and conversely lower flow velocities
and the transducer. In this arrangement blood
generate smaller Doppler shifted signals. If we can
flow moving away from the transducer produces
detect and measure the value of Fd then the Dopp-
received signals (Fr) which have a lower frequency
ler equation can be rearranged (see Equation 2) to
than the transmitted beam (Ft). This time the
calculate blood flow velocities (V) which can be
Doppler shifted frequencies (Fr
Ft) produces a
processed and displayed.
negative Doppler shifted signal.
When there is no flow or movement detected then
the transmitted frequency (Ft) is equal to the received Fd c
V¼
frequency (Fr). Therefore Fr ¼ Ft and Fd ¼ Fr
Ft ¼ 0, 2Ft cosy
resulting in no Doppler shifted signals. Equation 2: Doppler equation rearranged to calculate
It is important to appreciate that the amplitude blood flow velocities (V).
of the backscattered echoes from blood is much
weaker than those from soft tissue and organ
interfaces which are used to build up our B-mode Significance of the Doppler Angle (y)
anatomical images. The amplitude of the back-
scattered signal from blood can be smaller by a Ultrasound machines are able to calculate Doppler
factor of between 100 and 1000. Therefore highly shifted frequencies over a wide range of angles and
sensitive and sophisticated hardware and proces- it is important that an operator understands the
sing software is required to ensure that these significance of the angle of insonation (y) between
signals can be detected and processed. the Doppler beam and the direction of blood flow
in vessels. Figure 11.4 graphically shows how the
Doppler shifted signal changes as the Doppler
......................................................
THE DOPPLER EQUATION beam angle changes.
The Doppler equation shows the mathematical When the Doppler beam is pointing towards
relationship between the detected Doppler shifted the direction of blood flow a positive Doppler
signal (Fd) and the blood flow velocity (V): shifted signal is observed, but once the Doppler
beam is pointed away from the direction of blood
2Ft Vcosy
Fd ¼ flow a negative Doppler shifted signal is seen. The
c smaller the angle between the Doppler beam and
where: blood vessel, the larger the Doppler shifted signal.
Fd ¼ Doppler shifted signal Very small signals are produced as the Doppler
Ft ¼ transmitted Doppler frequency
beam angle approaches a 90 angle.
c ¼ the propagation speed of ultrasound in soft tissue
Table 11.1 shows the relationship between the
(1540 ms
1) angle of the Doppler beam (y) and the value of
V ¼ velocity of the moving blood
cosy. The value of cosy varies with the angle from
y ¼ the angle between the Doppler ultrasound beam
0 to 1. When y ¼ 0 , cosy ¼ 1 and when y ¼ 90 ,
and the direction of blood flow
cosy ¼ 0.
The number 2 is a constant indicating that the Doppler
For a constant flow velocity (V), the maximum
beam must travel to the moving target and then back to
value of cosy and therefore the highest value of
the transducer.
the Doppler shifted signal (Fd) is at an angle of
Equation 1: The Doppler equation. 0 . This corresponds to a Doppler beam which is
76
 Physical principles of Doppler ultrasound

Blood flow

Fig. 11.4 · Graphically demonstrating the relationship between the Doppler shifted frequency with respect to the
angle of the insonating Doppler beam

60 and remember no Doppler shifted signals are

ANGLE u VALUE OF COSu generated at 90 .
Greater flow velocities and smaller angles pro-
0 1
duce larger Doppler shifted frequencies, but not
30 0.87 stronger Doppler shift signals.
45 0.71
60 0.5 Typical Doppler Shifted Signals for Blood Flow
75 0.26 Ultrasound machines transmit high-frequency
sound waves which lie in the megahertz range,
90 0 typically between 2 MHz and 20 MHz. Substitut-
Table 11.1 Variation of the value of cosy over a range ing typical physiological blood flow velocities
of angles of insonation. Maximum value of cosy into the Doppler equation gives Doppler shifted
corresponds to a Doppler beam angle of 0 . signals which lie within the audible range. That
is, the range of frequencies that the human ear
can hear. A healthy young human can usually hear
parallel with the vessel, which can rarely be from 20 cycles per second to around 20 000 cycles
achieved in practice. per second (20 Hz to 20 kHz).
Theoretically, when y ¼ 90 this means the Let us calculate a typical Doppler signal fre-
blood flow is perpendicular to the Doppler beam, quency for blood moving at 0.5 ms
1 which is
cosy ¼ 0 and no Doppler shifted signals will illustrated in Figure 11.5. Transmitted frequency
register. (Ft) is 4 MHz, y ¼ 60 and c (the propagation
In practice, when taking measurements of speed of ultrasound) is assumed constant at
blood flow, a Doppler beam angle of between 30 1540 ms
1.
and 60 is important to ensure reliable Doppler Using the Doppler equation (Equation 1) we
shifted signals. Avoid using angles greater than calculate the Doppler shifted frequency to be
77
11 Ultrasound physics and technology

The Doppler equation Continuous Wave Doppler Devices

Continuous wave (CW) Doppler devices are the
2FtVcosθ
Fd =
c simplest of Doppler instruments and typically con-
sist of a handheld unit with an integrated speaker
• Typical values which is connected to a pencil probe transducer
– transmitted frequency 4 MHz
– blood velocity 0.5 ms–1 (Fig. 11.6).
– speed of sound 1540 ms–1 The transducer consists of two piezoelectric ele-
–θ 60⬚ ments: one element acts as a continuous transmitter
– Doppler shift frequency
(Ft) and the other acts as a continuous receiver (Fr).
– Fd = 1299 cycles per second These two elements are set at an angle to each
– Fd = 1300 Hz or 1.3 kHz other so that the transmit and reception beams
– i.e. in audible range overlap one another, as illustrated in Figure 11.7.
– simply can convert the Doppler shifted signal into an audible
This crossover region is known as the active or sen-
signal which can be heard through a loudspeaker
sitive area and is where Doppler signals can only
Fig. 11.5 · Illustrates the calculated Doppler shifted be detected. Doppler shift signals (Fd) are detected
signal using the Doppler equation for blood flow
moving at 50 cm/s for a Doppler beam operating at by comparing the transmitted and received signals:
4 MHz positioned with an insonation angle of 60 Fd ¼ Fr
Ft.
The frequency and angle between the two ele-
ments within the transducer are determined by
1299 cycles per second, about 1300 Hz or abbre-
the clinical application.
viated to 1.3 kHz.
For example, using CW Doppler in obstetrics for
These generated Doppler shifted signals can sim-
fetal heart monitoring requires a sufficiently low-
ply be converted into an audible signal which can
frequency Doppler signal to be able to penetrate to
be heard and monitored through a loudspeaker.
the required depth; typically 4 MHz is used. The
angle and therefore active crossover region between
TYPES OF DOPPLER INSTRUMENTATION the two elements is also set to correspond to the
......................................................
IN DIAGNOSTIC IMAGING required depth of integration.
Contrast this with the assessment of the
There are a number of types of Doppler instru-
mentation used in ultrasound which include: peripheral circulation in the legs. Here the CW
l continuous wave Doppler
Doppler device is required to detect blood flow
l color Doppler
in vessels which lie very close to the skin surface.
l power Doppler
So here a higher Doppler transmit frequency can
l spectral pulsed wave (PW) Doppler.
be used, typically 8 MHz, and the angle between
Doppler techniques applied to diagnostic ultra-
sound can be characterized as either being non- Loudspeaker output
imaging or imaging. Non-imaging techniques on handheld base
typically use small or handheld units, and use con- unit
tinuous wave (CW) Doppler. The main purpose of
these simple CW units is to either identify and/or
monitor blood flow. Two examples of clinical
examinations include fetal heart monitors in
obstetrics and peripheral blood flow assessment Pencil probe transducer
The transducer consists of
in vascular practice. two piezoelectric elements,
Imaging Doppler techniques such as color and a separate transmitter
spectral PW Doppler are always used with B-mode and receiver
imaging where the gray scale anatomical image is Fig. 11.6 · A simple CW Doppler device illustrating
used to identify blood vessels and areas for blood the two piezoelectric elements at the tip of the pencil
flow evaluation. These techniques require more probe transducer: one acting as a continuous
transmitter, the other acting as a continuous receiver
sophisticated processing than CW devices.
78
 Physical principles of Doppler ultrasound

CW DOPPLER DEVICES

Tra
nsm ADVANTAGES DISADVANTAGES
itte
rF
Re

t Small Cannot distinguish

ce
ive

multiple vessels within

r
Fr

crossover region
Cheap – simple design Cannot measure velocity
θ
Relatively easy to use Unable to provide
Blood flow and to search for a information about depth
vessel
Can display blood flow
Shaded area is known as patterns
the active or sensitive
region where Table 11.2 Comparative advantages and disadvantages
Doppler of CW Doppler.
signals (Fd) can only be
detected
Fd = Fr - Ft detected and monitored through a loudspeaker or
Fig. 11.7 · Elements within the transducer are set at a blood flow patterns can be displayed graphically.
fixed angle. Doppler signals only detected where the Table 11.2 summarizes the advantages and
transmitter and receiver beams overlap disadvantages of CW Doppler devices.

the two crystals within the probe is greater so that Doppler Imaging
the crossover region corresponds to the required There are three different types of Doppler imaging
depth of only a couple of centimeters. which will now be discussed:
There are various CW Doppler devices avail- 1 Color flow
able to detect blood flow. These range from simple 2 Power Doppler
inexpensive handheld Doppler units, where the 3 Spectral Doppler.
Doppler signal is processed to provide an audible
output, to more sophisticated devices which pro-
vide a visual display of the Doppler shifted blood
Color Flow Imaging
flow patterns.
The main disadvantage of CW devices is that Color flow imaging was first introduced in the
the transducer is sensitive to any blood flow mid 1980s and since then has extended the role
within the crossover region. If more than one ves- of ultrasound as a diagnostic tool. It can quickly
sel is present in this crossover region then Doppler and effectively enable the operator to identify the
signals are obtained from more than one vessel at presence and direction of blood flow in vessels
a time. Arteries and veins often lie adjacent to each and can highlight gross circulation anomalies
other so in many cases CW devices will simulta- within the anatomical B-mode image.
neously detect arterial and venous flow signals. It is probably the first Doppler technique that
In addition, CW devices are unable to provide an operator will utilize to investigate blood flow.
information on the depth from which the blood Color flow imaging is always used in conjunction
flow signals have returned and cannot measure with B-mode imaging and once it is activated the
blood flow velocity (V). operator is presented with a region of interest
The advantages of CW Doppler devices are that known as the ‘color box’ and vertical ‘color scale’
they are small and cheap and are relatively easy to bar which are superimposed onto the B-mode
use with minimal training. Blood flow can be image, as illustrated in Figure 11.8.
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11 Ultrasound physics and technology

Transducer

Additional color
scan lines
Individual sample
volume

Color box

Color Doppler flow information Color scale display usually B-mode image
superimposed on the B-mode image arranged to show flow towards
to provide a color map of blood flow and away from the ultrasound Fig. 11.9 · The color flow box is made up of hundreds
beam in two primary colors of scan lines. Each scan line consists of hundreds of
Fig. 11.8 · B-mode image with color flow information small sample volumes which individually detect the
superimposed. Note that color flow information is only backscattered Doppler ultrasound signals
mapped into the color box region. Vertical color scale
bar present on the right-hand side of the display thousands of sample volumes within the color
box.
For each individual sample volume along each
Unlike CW Doppler devices, where continuous scan line, the average or mean Doppler shifted
Doppler beams are generated and transmitted by velocity is calculated. This mean Doppler shifted
the two separate elements within the transducer, velocity, which can either be positive or negative,
color flow imaging uses small groups of elements is assigned a color which is then mapped onto a
to transmit and receive the Doppler signals. The color scale which consists of two primary colors.
Doppler signals consist of a series of short bursts This is usually red for positive Doppler shifted sig-
or pulses of ultrasound similar to those used in nals (corresponding to blood flow traveling
B-mode imaging. To form the color flow image, towards the transducer) and blue for negative
additional Doppler ultrasound pulses are gener- Doppler shifted signals (corresponding to blood
ated by the transducer which is typically three flow away from the transducer). This typical
to four times longer than those used for B-mode arrangement can be seen in Figure 11.8.
imaging. The transducer elements are rapidly Once this directional information is processed,
switched between B-mode and color flow imaging the sample volume is assigned a shade or hue
to give an impression of a combined simultaneous depending on the calculated mean velocity.
image, and this is often known as duplex imaging, The color flow information in the color box
duplex meaning ‘double’. is made up by processing the information in each
The position and size of this color box can sample volume along each scan line in turn. In
be adjusted to the chosen area of interest by the order to obtain a reliable estimation of the mean
operator to provide a visual color-coded display velocity in each sample volume, several (10 or more)
or map of blood flow. pulse-echo sequences are required to produce each
scan line of color flow information. This series of
pulse-echo sequences is then repeated for the next
The color box
adjacent scan line, and so on, as is the case for
The color image within the color box is made up B-mode imaging.
of hundreds of scan lines which are each sub- A consequence of this multi pulse-echo tech-
divided into small sample volumes as illustrated nique is that it takes more time to collect and
in Figure 11.9. Typically, there are hundreds of process the information required for color flow
sample volumes per scan line, amounting to imaging than it does for standard B-mode
80
 Physical principles of Doppler ultrasound

imaging. As a result, color flow images tend to blue. However, in most equipment this color bar
have lower frame rates than those used in B-mode. scale can be changed, if required, by the operator.

Color scale Significance of angle

The color scale is represented as a vertical color With any Doppler technique, angle is important.
bar and normally sits to the side of the B-mode The appearance of the color flow image is very
image (see Fig. 11.8). Closer inspection of the much dependent on the operator to obtain a suffi-
color bar shows that it consists of two primary cient angle between the Doppler ultrasound beam
colors with each primary color subdivided into and the vessel.
different shades or hues. Curvilinear and phased array transducers have a
Just as in B-mode imaging, where returning radiating pattern of ultrasound beams that can
echo amplitudes are assigned a varying level of produce complex color flow images, depending
gray to form the B-mode image (higher echo on the orientation of the arteries and veins with
amplitudes are assigned brighter levels of gray respect to the Doppler beam. This can be seen in
and low amplitude echoes are assigned darker Figure 11.11 which presents a color flow image
shades of gray), in color flow imaging similarly of an umbilical cord.
higher calculated mean flow velocities are assigned Many peripheral vessels run parallel to the face
varying hues of red and blue. The higher the of a linear transducer and perpendicular to the
velocity, the brighter the shade or hue assigned. Doppler beam. If the angle of the Doppler beam
Figure 11.10 illustrates a typical color scale bar with respect to the vessel is at 90 , little or no
used. As you can see, it consists of a vertical color Doppler signal will be detected, as seen in
bar which is split from the center into two primary Figure 11.12. When using a linear array transducer
colors. The center of a standard color bar scale the operator is able to overcome this problem by
represents zero or no flow. In this case, blood flow electronically steering the Doppler beam. This is
towards the transducer will be labeled red and performed by altering the angle of the color box,
blood flow away from the transducer is labeled as illustrated in Figure 11.13. The objective is to

Red Maximum velocity

+28
+27
+26
Flow towards +25 Flow towards
the transducer the transducer

+2
+1
Baseline 0 Zero velocity
–1
–2

Flow away from Flow away from

the transducer –25 the transducer
–26
–27
–28
Blue Maximum velocity
Fig. 11.10 · Typical color scale bar. Blood flowing towards the transducer is displayed as RED, blood flowing
away from the transducer is BLUE. The brighter shades indicate higher velocities
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11 Ultrasound physics and technology

Fig. 11.11 · Color flow imaging of an umbilical cord

highlighting the complex pattern of blood flow
Fig. 11.13 · Color flow image of the common carotid
artery with a steered color box to obtain sufficient
angles for reliable Doppler signals

The color flow information is not built up con-

tinuously, as is the case with CW Doppler devices,
but is formed from a series of Doppler ultrasound
pulses which are transmitted at a given rate known
as the sampling frequency.
In order to measure the many Doppler shifted
frequencies present in typical blood flow patterns,
thousands of pulses are sent along each scan line
in turn. These sampled pulses are used to build
up the Doppler shifted signal and in order to accu-
rately build the Doppler shifted signal there must
be an adequate number of samples per second.
Aliasing is the incorrect estimation of Doppler
shifted signals due to undersampling which causes
a false lower Doppler shifted frequency signal to
Fig. 11.12 · Color flow imaging demonstrating that appear in the sampled signal. Figure 11.14 shows
no Doppler signal is registered when the vessel is at
90 with the Doppler beam

A
obtain a sufficiently small angle between the
Doppler beam and blood vessel to provide reliable
Doppler signals.
In practice, an experienced operator alters the
Aliased signal due to undersampling
scanning approach and steers the Doppler beam to
obtain good angles between the Doppler beam and B
vessel to avoid unambiguous color flow images.

Aliasing
Adequately sampled signal
Aliasing occurs with all pulsed wave Doppler
instruments because they employ a sampling Fig. 11.14 · a) Undersampled signal; b) adequately
sampled signal
method to build up the Doppler shifted signals.
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 Physical principles of Doppler ultrasound

an undersampled signal and an adequately sam- to the maximum Doppler shifted signals (Fd) that
pled signal of a simple sine wave. can be detected. The maximum Doppler shifted
In Figure 11.14a the undersampled signal signal Fd that can be measured is restricted, and is
appears to have a lower frequency than the actual equal to half the pulse repetition frequency of the
signal – two cycles instead of ten cycles. system, which is mathematically represented below:
Increasing the sampling frequency as demon-
strated in Figure 11.14b increases the number of PRF
Fd ¼
data points acquired in a given time period. 2
A rapid sampling frequency provides a better rep-
resentation of the original signal than a slower This condition is known as the Nyquist limit. If
sampling frequency. the Nyquist limit is exceeded then aliasing will
The effect of aliasing can be seen when watching occur. When aliasing occurs, the displayed colors
films where wagon wheels can appear to be going ‘wrap around’ the color scale bar and the colors
backwards instead of forwards due to the low frame change from the maximum color in one direction
rate of the film causing misinterpretation of the to the maximum in the opposite direction.
movement of the wheel spokes. The true velocity Figure 11.15a illustrates color aliasing which is
and correct direction of the wheel is only seen if caused when the color scale is set too low. The
the film’s frame rate is rapid enough. Doppler signals are undersampled at a PRF ¼
12.5 kHz which corresponds to a maximum color
Significance of pulse repetition frequency scale velocity of 13.9 cm/s. In this example, color
The frequency, i.e. sampling rate, at which these flow changes from BLUE to RED are observed
pulses can be sent is determined by the system’s within the vessel. Increasing the color scale
pulse repetition frequency (PRF) which can be increases the PRF, from 12.5 kHz to 14 kHz, which
adjusted through the color scale control button. is sufficient enough to eliminate aliasing within the
Increasing the color scale increases the system’s image, as demonstrated in Figure 11.15b.
PRF and, conversely, reducing the color scale will
reduce the system’s PRF.
Significance of depth
There is an upper limit to the system’s PRF, i.e.
color scale, which is restricted to the time the system A relationship exists between the maximum veloc-
has to wait to receive all the returning echoes along ity of blood that can be detected and the maximum
each scan line before sending another. This is linked depth at which a vessel is investigated. As the depth

Fig. 11.15 · a) The color scale is set too low, resulting in aliasing of the color Doppler signal. The Doppler signals
are undersampled at a PRF ¼ 12.5 kHz. b) The color scale and PRF are increased to ensure that the Doppler
signals are adequately sampled, resulting in the elimination of aliasing. This is achieved at a higher PRF of 14 kHz

83
11 Ultrasound physics and technology

of investigation increases, the journey time of the

pulse to and from the reflector is increased; this in
turn reduces the system’s PRF. This reduction in
the system’s PRF reduces the maximum Doppler
shifted signal (Fd) that can be displayed before
aliasing occurs. The result is that the maximum
Doppler shifted signals (Fd) which can be measured
decrease with depth.

Advantages and limitations of color flow imaging

Advantages Fig. 11.16 · Power Doppler image of the carotid

bifurcation
l Gives an overall view of flow within a region
l Indicates flow direction
l Identifies areas of turbulent flow velocities
and anomalies
l Indicates absence of flow in occluded vessels. l not being subject to aliasing as it does not
use a sampling technique
Limitations include l providing better edge detection, e.g. around

l Flow information limited to mean velocity arterial plaques.

l Poor temporal resolution – frame rate can be But it has the disadvantages of:
low when scanning deep l displaying no direction of flow velocity

l Subject to aliasing information

l Angle dependent. l being subject to very poor temporal

resolution – a high degree of frame averaging

is used
Power Doppler l being extremely sensitive to motion – which

Power Doppler is also referred to as energy means that the transducer needs to be kept
Doppler, amplitude Doppler and Doppler angio- still to give good images.
graphy. It is a color flow imaging technique that
maps the magnitude, i.e. power, of the backscat-
Spectral or Pulse Wave Doppler
tered Doppler signal rather than the Doppler
shifted flow velocities. The instantaneous signal Spectral Doppler, also referred to as pulsed wave
strength contained in the Doppler signal is calcu- (PW) Doppler, is combined with B-mode and
lated and superimposed onto the B-mode image color flow imaging techniques and allows for the
as illustrated in Figure 11.16. Its effect is to pro- assessment and evaluation of the blood flow over
vide a map of areas of perfusion, by displaying a very small region known as the sample volume.
the amplitude of red blood cells in an area. This technique is known as range gating.
Power Doppler does not display the relative When spectral Doppler is initially instigated, a
velocity and direction of blood flow as is the case single Doppler beam axis is superimposed onto
with color flow imaging. Power Doppler uses a the B-mode and color flow image as illustrated in
single color scale and maps increasing signal Figure 11.17. The size and position of the sample
strengths to increased luminosity. It is often used volume can be adjusted anywhere along the axis
in conjunction with frame averaging to increase of the Doppler beam and this information is dis-
sensitivity to low flows and velocities. played on the monitor. The position of the sample
Power Doppler has several advantages over volume determines where along the Doppler
color flow imaging which include: beam blood flow velocities are to be investigated.
l being more sensitive to flow and detecting The size of the sample volume determines how
low flows. The display of backscattered much of the vessel is examined. For arterial exam-
power is independent of angle inations, the sample volume is positioned in the
84
 Physical principles of Doppler ultrasound

Fig. 11.17 · Illustration of the on-screen components when spectral Doppler is activated. Highlighting the Doppler
beam axis, the sample volume, and angle correction cursor. The size and position of the sample volume is always
displayed on screen

center of the vessel, and the size of the sample vol- The angle correction cursor which is located
ume is set to be approximately one half to one at the center of the sample volume is used to esti-
third of the diameter of the vessel. mate the angle of insonation between vessel and
When the sample volume has been correctly Doppler beam and should be adjusted to align
positioned over a point of interest then the spec- with the direction of blood flow in the vessel to
tral Doppler display is activated to provide blood calculate absolute flow velocities from the detected
flow velocity information. Doppler shifted signals.
The Doppler beam itself can be maneuvered By angle correcting, the operator provides the
over the B-mode image and follows the path of ultrasound system with the actual value of y in
the B-mode imaging scan lines for a sector array the Doppler equation. Once y is known, the
transducer, as depicted in Figure 11.17. When lin- Doppler equation can be used to calculate actual
ear array transducers are used, the Doppler beam blood flow velocities. Accurate and reliable spec-
can be steered, which enables the operator to tral Doppler flow velocities are achieved for angles
achieve the necessary angle between the Doppler of y, between the Doppler beam and the direction
beam and blood vessel under investigation. An of blood flow, which are no greater than 60 .
example of this is shown in Figure 11.18. Color flow imaging which maps blood flow
over a much larger area is used in conjunction
with spectral Doppler, highlighting areas of dis-
turbed or turbulent blood flow for spectral Dopp-
ler assessment.
Spectral Doppler, combined with real-time
B-mode and color flow imaging, is known as tri-
plex imaging. When triplex imaging is used by
the operator, data collecting and processing is
shared between all three modes. This reduces the
overall imaging frame rate and Doppler sampling
frequency, which in turn restricts the range over
which blood flow velocities can be measured.
Fig. 11.18 · An example of a linear array transducer Optimum spectral Doppler assessments are
electronically steering both the color and spectral achieved when B-mode and color flow imaging
Doppler beams to obtain a sufficient angle between modes are temporarily frozen which allows more
the Doppler beam and blood vessel for reliable time to be employed for rapid spectral Doppler
Doppler assessment processing.
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11 Ultrasound physics and technology

Generation of spectral PW Doppler signals

Spectral Doppler is similar to color flow imaging in
the way that it utilizes a sampling technique to
build up the spectral Doppler shifted signals. As is
the case for B-mode imaging, a small group of ele-
ments within the transducer acts as both a transmit-
ter and receiver of Doppler ultrasound, transmitting
regular short bursts of spectral Doppler signals
from which received Doppler shifted signals are
processed. However, spectral Doppler only sends Fig. 11.20 · Spectral waveform of a femoral artery
displaying time along the horizontal axis and flow
out one beam, unlike color Doppler which requires velocities along the vertical axis
many adjacent beams to form the color flow image.
The pulses generated for spectral Doppler differ
from those used for B-mode imaging and tend to horizontal axis and flow velocities (calculated
be longer, typically 6–10 cycles in length. from the Doppler shifted signals) along the verti-
cal axis. The vertical axis is divided into two so that
Processing and displaying the PW Doppler signal both positive and negative Doppler shifted signals
can be displayed. The baseline relates to zero flow.
Spectral Doppler provides more detailed informa- Both the velocity scale and baseline can be
tion of blood flow than color flow imaging and adjusted by the operator to ensure that spectral
is able to map the variation and distribution waveforms are optimally displayed.
of blood flow velocities over the cardiac cycle. The third axis of the spectral trace corresponds
The spectral Doppler signal contains all this to the backscattered power of the Doppler shifted
information. signal at each velocity. This is simply displayed as
Doppler signals are processed using spectral brightness which is illustrated in Figure 11.21.
analysis to provide a more meaningful and useful Spectral analysis is performed by the ultrasound
way to represent the Doppler velocity informa- machine’s on-board computer using a mathematical
tion visually. Spectral analysis breaks down the technique known as a fast Fourier transform (FFT)
Doppler signals received within the sample vol- and produces between 100–200 lines of processed
ume into its range of frequency components, data every second. PW Doppler systems are
which are translated into a range of flow velocities. able to process information fast enough to produce
The process of spectral analysis can be thought of real-time spectral Doppler waveforms and, as a con-
as being similar to using a prism to split visible sequence of this, rapid processing is said to have
light into its separate components, i.e. its color good temporal resolution.
spectrum, as seen in Figure 11.19.
Figure 11.20 shows a typical spectral analysis
trace for a femoral artery, with time along the
The third axis displays brightness which
corresponds to the backscattered power of the
Doppler shifted signal at each velocity
Velocity

100–200 lines of spectral data

are generated per second

Time
Fig. 11.21 · A spectral analysis trace displaying the
Fig. 11.19 · A prism splitting light into its individual variation of velocities over the cardiac cycle. The
components is similar to the process employed by brightness corresponds to the backscattered power
spectral analysis of the Doppler shifted signal at each velocity
86
 Physical principles of Doppler ultrasound

Aliasing
Because spectral Doppler uses a sampling tech-
nique to interrogate and build up information
about the blood flow velocities, it is subject to
aliasing. As discussed under Color Flow Imaging,
aliasing is governed by the system’s Doppler PRF
which can be adjusted through the spectral Dopp-
ler ‘scale’ control. The maximum velocity that can
be measured is directly proportional to half the
value of the PRF. The higher the pulse repetition
frequency of the Doppler pulses, the higher the
Doppler shifted velocity that can be measured.
Fig. 11.22 · Example of aliasing and correction of the
The PRF is also linked to the position (i.e. the
aliasing. a) Waveforms with aliasing wrap around the
depth) of the sample volume. The deeper the velocity scale resulting in the peaks being displayed
sample volume is placed within the B-mode below the baseline. b) Aliasing avoided with the same
image, the lower the value of the PRF due to time spectral waveform achieved by increasing the pulse
constraints, i.e. the system has to wait longer to repetition frequency, i.e. increasing the velocity scale
receive the reflected Doppler pulses from a sample
volume which is placed deep within the image
rather than one which is positioned close to the
l Reduce transmitted frequency (Ft) as the
transducer. The relationship between PRF, the Doppler equation shows that the Doppler
maximum measurable velocity, and the depth of shifted frequency (Fd) is proportional to Ft so
the sample volume are summarized in Table 11.3. lower Ft will lower the value of Fd
The effects of aliasing are demonstrated in
l Reduce the angle (y) between the Doppler
Figure 11.22 and cannot always be eliminated, as beam and vessel.
it is not always possible to have the PRF significantly
higher than the Doppler shifted signal. However, Advantages and disadvantages of spectral Doppler
these effects can be minimized by adjusting the fol-
lowing controls: Advantages
l Increase vertical spectral velocity scale which l Examines flow at one site
in turn increases the system’s PRF l Good temporal resolution – gives detailed
l Offset zero baseline on PW spectrum which analysis of distribution of blood flow
is only possible if the flow is significantly in velocities over the cardiac cycle
one direction l Can make calculations of flow velocities.

ACTION CONSEQUENCE

As PRF increases Maximum measurable velocity

increases
As PRF decreases Maximum measurable velocity
decreases
As the depth of sample volume PRF decreases Maximum measurable velocity
increases decreases
As the depth of sample volume PRF increases Maximum measurable velocity
decreases increases

Table 11.3 Demonstrating the relationship between PRF, maximum measurable velocity, and depth of sample volume.
87
11 Ultrasound physics and technology

Disadvantages incorrect estimation of Doppler shifted signals

l Uses a sampling technique and therefore is due to undersampling. When aliasing occurs, the
subject to aliasing displayed Doppler shifted signals ‘wrap around’
l Limit on maximum velocity that can be the Doppler velocity scale and the Doppler shifted
measured – governed by PRF signals change from the maximum velocity in one
l Angle dependent. direction to the maximum in the opposite direc-
Table 11.4 summarizes and compares these three tion. Figures 11.15 and 11.22 demonstrate the
Doppler modes. effects of aliasing upon the color and spectral
Doppler imaging displays.

......................................................
DOPPLER ARTIFACTS
Aliasing Doppler Mirror Image
Aliasing is the most common Doppler artifact and This type of artifact can be seen in both spectral
occurs with all pulsed wave Doppler instruments Doppler and color flow imaging.
because they employ a sampling method to build This mirror artifact can be seen in spectral
up the Doppler shifted signals. Aliasing is the Doppler traces where there is electronic duplica-
tion of spectral information being displayed
below the zero baseline, as seen in Figure 11.23.
DOPPLER FLOW MAIN ADVANTAGES AND
It commonly results from the Doppler receiver
IMAGING MODE DISADVANTAGES
gain being set too high.
Color flow imaging  Gives an overall view of Color images can also produce mirror artifacts
flow within a region and can normally be seen where a vessel lies above
 Identifies turbulent flow a strong reflecting surface. Figure 11.24 shows a
velocities mirror image of the subclavian artery produced
 Flow information limited to
by multiple reflections from the pleura above the
mean velocity
 Poor temporal resolution – lung, where there is a soft-tissue/air boundary
frame rate can be low present, causing strong reflections.
when scanning deep
 Subject to aliasing
 Angle dependent

Power Doppler  Sensitive to low flows

 No directional information
 Very poor temporal
resolution – susceptible to
transducer movement
 Not angle dependent

Spectral Doppler  Examines flow at one site

 Good temporal resolution –
gives detailed analysis of
distribution of blood flow
velocities over the cardiac
cycle
 Can make calculations of
flow velocities
 Subject to aliasing
 Limit on maximum velocity
that can be measured –
governed by PRF
 Angle dependent

Table 11.4 Comparison and summary of Doppler flow Fig. 11.23 · Demonstrating spectral Doppler mirror
imaging modes. artifact due to the receiver gain being set too high
88
 Physical principles of Doppler ultrasound

Fig. 11.25 · Demonstrating flashes of color seen

within the image brought about by rapid movements
of either the transducer or tissues by respiration
Fig. 11.24 · Color image of the subclavian artery with a
mirror image below the pleura

Flash artifact
tion or rapid transducer movement, for example,
Both color flow and power Doppler imaging use can cause significant flashes of color across large
filters to suppress signals arising from stationary areas within the color flow image. Some machines
or near stationary tissue. However, large move- have motion suppression algorithms to reduce this
ments of tissues brought about by heavy respira- flash artifact. This is illustrated in Figure 11.25.

SUMMARY
· The Doppler effect can be applied in diagnostic ultrasound to detect the movement of internal structures and
the motion of blood flow
· There is a range of Doppler instruments available, from simple handheld CW devices to more complicated and
sophisticated Doppler imaging machines
· Doppler imaging instruments make use of the Doppler effect to process information which can display the
motion, direction, and velocity of blood flow
· Doppler signals are subject to angle dependence
· Color flow imaging and spectral Doppler use a sampling technique to build up the Doppler signals and as a
consequence of this are subject to aliasing
· Artifacts can occur with Doppler ultrasound instruments and include aliasing, mirroring, and flash artifact

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 Ultrasound safety
12
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 Outline the parameters used to describe the

Introduction 91
strength of an ultrasound beam.
Why are we interested? 92
2 Discuss the significance of different operating
Operating modes and their potential modes and their potential risk of producing
risk 93 biological effects.
Who regulates ultrasound acoustic 3 Be aware of current diagnostic ultrasound
output limits? 94 output limits.
Output display standards 94 4 Describe the thermal and non-thermal
physical mechanisms that can cause biological
Biological effects of ultrasound 94 effects.
Prudent use – the ALARA principle 97 5 Explain the thermal index (TI) and mechanical
General guidelines 97 index (MI) and understand the significance of
these in relation to causing a potential
Machine controls which influence biological hazard.
hazard 98
6 Be aware of the general guidelines offered by
Epidemiological evidence 98 ultrasound organizations and societies.
7 Discuss the influence of the machine controls.
8 Outline the ways to limit exposure by adopting
the ALARA principle.
9 Have a basic appreciation of epidemiological
evidence.

......................................................
INTRODUCTION
There has been a considerable and rapid growth in
the use of ultrasound as a diagnostic imaging tool
over the past 50 years since it was first used to
image the unborn fetus. This rapid growth has
resulted in millions of people worldwide being
scanned every year. Changes and advances in tech-
nology are leading to increasing power levels
being used to obtain diagnostic information. The
interaction of ultrasound with biological tissue

91
12 Ultrasound physics and technology

can result in effects which may cause heating, wave per unit of time. Power is measured in watts
interfere with the normal functioning of cells, (W) and milliwatts (mW), one milliwatt being one
and cause structural damage. The potential damag- thousandth of a watt. Power is proportional to
ing nature of ultrasound leads to concern over the square of the amplitude, i.e. if the power is
its safety. All operators therefore need to have an doubled then the amplitude is quadrupled.
understanding of the safety implications in order
to practice safely. Intensity (I)
Intensity is the rate at which energy passes through
......................................................
WHY ARE WE INTERESTED? the unit area and is an important quantity when
discussing bioeffects and safety.
Ultrasound is a mechanical form of energy which
interacts with the biological tissue through which it The average intensity is equal to the power of an
travels. Millions of women have their pregnancy ultrasound beam, normally expressed in mW,
routinely scanned with ultrasound and any adverse divided by the cross-sectional area of the beam,
effects are more likely to damage the rapidly devel- expressed in cm2. Units of intensity for diagnostic
oping cells found in embryo, fetus, and neonate. ultrasound are typically expressed in mWcm
2.
New research is continually being carried out, From the equation in Figure 12.2 we can identify
but variable parameters of ultrasound exposure that the intensity of an ultrasound beam is directly
and mechanisms of interaction with tissue lead proportional to its power, i.e. if beam power
to problems in determining when safe levels are increases, then intensity increases and, conversely,
being breached. if beam power decreases, the intensity decreases.
In addition, we can see that intensity is also
inversely proportional to the beam area, i.e. if
Important Parameters the beam area decreases, then the beam intensity
Amplitude, power, and intensity are parameters used increases and, conversely, if the beam area increases,
to describe the strength of an ultrasound beam. the beam intensity decreases.
The maximum intensity along an ultrasound beam
Amplitude lies at the focus (the narrowest part of the beam)
Amplitude is a measure of a wave’s magnitude of
oscillation, that is, the magnitude of the maximum
disturbance in the medium, and in ultrasound often
refers to the maximum variation (see Fig. 12.1). Cross-sectional area
Amplitude is measured in units of pressure: MPa
(megapascals).
Power (P)
Power in ultrasound describes the rate at which
energy is generated and transferred by the acoustic
Power (mW)
2 Intensity =
Area (cm2)

1
Pressure (MPa)

0 Typical ultrasound
beam profile
–1

–2
Time or distance Fig. 12.2 · Diagram showing a typical ultrasound beam
Amplitude profile and a cross-sectional area. Cross-sectional area
Fig. 12.1 · Demonstrating the varying pressure varies with depth and is smallest at the focus where the
amplitude of an oscillating acoustic wave intensity is the highest

92
 Ultrasound safety

where all the power is concentrated into a small l Pulse average intensity (IPA) – is the intensity
cross-sectional area. averaged over the pulse duration. Lies in
The intensity within an ultrasound beam also between ITP and ITA
varies from point to point across the beam (spatial l Temporal average intensity (ITA) – takes

considerations), as demonstrated in Figure 12.3. account of the ‘dead’ time between pulses
Two values of intensity can de defined: and is averaged over the pulse repetition
l Spatial peak intensity (ISP) – is the highest period (PRP). It is the lowest value.
intensity and is found at the center of the These spatial and temporal variations within the
beam ultrasound beam result in the fact that there are
l Spatial average intensity (ISA) – is the average a number of ways of defining intensity, as detailed
intensity across the beam and takes account below:
of the variation across the width of the beam.
Because of the pulsed nature of ultrasound, the Highest ISPTP – Spatial peak-temporal peak (SPTP)
intensity of the ultrasound beam also varies over intensity
ISATP – Spatial average-temporal peak (SATP)
time (temporal considerations). Figure 12.4 shows
the relevant times for three intensities: ISPPA – Spatial peak-pulse average (SPPA)
l Temporal peak intensity (ITP) – is the highest
ISAPA – Spatial average-pulse average (SAPA)
intensity found in a pulse and is not averaged
over time ISPTA – Spatial peak-temporal average (SPTA)

Lowest ISATA – Spatial average-temporal average

intensity (SATA)

Spatial peak intensity ISPTA is the measure most associated with tempera-
ture rises.
Intensity mW/cm2

OPERATING MODES AND THEIR

Spatial average intensity ......................................................
POTENTIAL RISK
For any operating mode there is a large variation
of output powers and intensities. The output data
for all modern day ultrasound machines can be
Center sourced from the operator’s manual.
Distance across beam
Exposures used in Doppler modes such as spec-
Fig. 12.3 · Demonstrating the variation of intensity tral pulsed Doppler and color flow imaging are
across an ultrasound beam. The spatial intensity across higher than for B and M modes.
the beam is at its highest at the center, tailing off
towards the edges
B modes
Uses the lowest output power and intensities and
TA = pulse repetition period
TP is generally considered safe in all applications.
Pressure

Pulsed Doppler
The longer pulses, higher powers, and pulse repeti-
tion rates typically used in pulsed Doppler result
Time in higher average intensities compared to B-mode
PA = pulse duration imaging and therefore there is an increased poten-
Fig. 12.4 · Demonstrating the three time-dependent tial of producing a biological effect, particularly
intensities from ultrasound-induced heating.
93
12 Ultrasound physics and technology

Dwell time, i.e. the length of time that the ultra- output. Its purpose is to inform the user of the
sound beam is fixed on a specific tissue area, is an potential risk for an examination to produce a
important factor when considering the potential for biological effect. This shifted the onus of safety to
heating. This is particularly relevant for spectral the end user who is now responsible for making a
pulsed Doppler where the beam is held in a fixed risk/benefit assessment. This requires the ultrasound
position during an investigation; this leads to a user to understand the potential for biological
further increase in temporal average intensity and effects and practice to ensure exposure times are
therefore increased risk of causing a temperature kept to a minimum.
rise.

Color Flow Mapping and Power Doppler ......................................................

OUTPUT DISPLAY STANDARDS
Imaging Modes In 1992, the American Institute of Ultrasound
These modes involve some beam scanning, and so in Medicine (AIUM) and the National Electrical
generally have a heating potential that is some- Manufacturers Association (NEMA) defined a set
where between that of B-mode and that of spectral of output display standards (ODS). For each ultra-
pulsed Doppler. sound examination, a real-time on-screen display
Table 12.1 summarizes data collected from a indicates the risk of producing biological effects.
survey conducted by Henderson in 1997. Here ODS is based on two indices which give two main
you can see that the highest intensities are pro- measures of output:
l TI ¼ Thermal effects (related to average
duced when using pulsed Doppler modes.
intensity)
l MI ¼ Cavitation – non-thermal (related to
WHO REGULATES ULTRASOUND
......................................................
ACOUSTIC OUTPUT LIMITS? peak pressure).
This enables users to be aware of output levels dur-
Surprisingly enough, these are not regulated by ing scanning.
a medical body. Regulations governing the output These increases in output levels have also driven
of diagnostic ultrasound have been largely set by some of the improvements and developments in
the USA’s Food and Drug Administration (FDA). diagnostic ultrasound that we mentioned earlier,
In 1991 the FDA relaxed its regulations and increa- to the extent that modern ultrasound equipment is
sed the permissible acoustic output and intensity capable of producing measurable biological effects
levels used to scan early pregnancy to almost eight in tissues (Barnett 1998, Barnett & Kossoff 1992).
times over the level that had been previously allowed
(from 94 to 720 mWcm
2). Table 12.2 shows these
changes in acoustic output levels in relation to the
range of diagnostic areas.
......................................................
BIOLOGICAL EFFECTS OF ULTRASOUND
Physical Mechanisms
However, for the manufacturers to utilize these
increased output levels and higher intensities, Clinically we know ultrasound energy can be
it was agreed that their equipment should provide utilized in lithotripsy by using a focused, high-
an on-screen display relating to the acoustic intensity acoustic pulse to destroy a kidney stone.

OPERATING MODE POWER MEAN ISPTA (mWcm-2) POTENTIAL RISK

Pulsed Doppler Highest 1700 Highest risk for possible heating

Color Doppler 450 Risk of heating with small color boxes
B mode Lowest 200 Considered safe

Table 12.1 Values of the UK survey of equipment in clinical use (from Henderson et al 1997).
94
 Ultrasound safety

significant when using endocavity probes which

APPLICATION BEFORE 1991 AFTER 1991 use higher frequencies to improve image quality.
(PRE ODS) WITH ODS
The ultrasound intensity varies along the ultra-
INTENSITY INTENSITY
LIMIT (ISPTA) LIMIT (ISPTA) sound beam and is greatest at the focus where
(mWcm
2) (mWcm
2) the beam is at its narrowest. The intensity can be
changed by other operator controls such as power
Fetal, neonatal 94 720 output, scan depth, and mode of operation, i.e.
imaging using color and Doppler modes.
Cardiac 430 720 Heat can also be produced at the transducer
surface which can be directly transferred to the tis-
Peripheral 720 720 sue it is in contact with. This can be particularly
vascular
significant when using transvaginal probes to
Ophthalmology 17 50 investigate a pregnancy during the first eight weeks
postconception.
Table 12.2 Shows the changes to maximum allowable The World Federation for Ultrasound in Medi-
output exposure following the changes stipulated by the
US FDA. ODS; output display standards. cine and Biology (WFUMB; Barnett 1998), follow-
ing a review of the literature on the effects of
temperature elevation on animal fetuses, concluded
These devices use energies much higher than those that a temperature rise of no more than 1.5 C may
utilized in diagnostic ultrasound, however it can be used clinically without reservation, however,
be easily demonstrated that there is potential for exposures that elevate embryonic and fetal tempera-
destruction. tures higher than 4 C for 5 minutes or more should
There are two distinct mechanisms that can be considered as potentially hazardous.
cause biological effects on tissue when exposed
to ultrasound. These are: Thermal index (TI)
l Thermal (heating) The thermal index (TI) as defined by AIUM/NEMA
l Non-thermal effects (cavitation). is the ratio of the acoustic power produced by the
transducer (W) to the power required to raise the
Thermal effects temperature in tissue by 1 C (Wdeg). This is math-
As the ultrasound beam travels through tissue, ematically expressed in Equation 1:
some of its energy is lost through absorption. This W
absorbed energy is converted into heat which in turn TI ¼
Wdeg
produces a temperature rise. In most soft tissues, the
rate at which energy is absorbed depends on the: Equation 1: Formula for thermal index.
l attenuation coefficient of the tissue

l operating frequency (Derated values compensate for attenuation by

l power/intensity of the ultrasound beam soft tissue. Acoustic output measurements are usu-
l length of operating time (exposure time). ally performed in a water tank. To take into
The thermal effect is highest in tissues with a high account the attenuation by soft tissue in practice,
absorption coefficient such as bone, and is low these values are adjusted, i.e. ‘derated’, using a
where there is little absorption such as amniotic value of attenuation of 0.3 dB/cm/MHz.)
fluid (water). A thermal index of 1 indicates the acoustic
The potential of any temperature rise also power achieving a temperature increase of 1 C.
depends on the thermal characteristics of the tissue A thermal index of 2 has doubled power but
to dissipate this heat to surrounding areas, the would not necessarily indicate a peak temperature
ultrasound intensity, and the length of time for rise of 2 C. The algorithms in the machine which
which the tissue volume is scanned. calculate TI are based on many assumptions and
Frequency is another factor and the higher the take into account a worst case scenario such as
operating frequency, the higher the absorption low levels of beam attenuation, a stationary beam,
and potential to cause heat. This is particularly and fairly long exposure times.
95
12 Ultrasound physics and technology

There are several classifications of thermal indices: bubbles to collapse. Small laboratory mammalian
l TIS – this is the thermal index applied experiments have demonstrated this effect in lung
when you are scanning through a soft-tissue and intestine, where small gas bubbles can be
structure and will probably be the one you present. The most important sources of cavitation
most often encounter are those introduced during contrast studies.
l TIB – this is the thermal index which applies if Above diagnostic output levels, cavitation plays
bone is at or near the focus of the transducer. an important role in the destruction of kidney
Remember, because of its high acoustic stones in shock wave lithotripsy.
absorption, there is an increased potential for There are two forms of cavitation:
heating which will be reflected in the values l Stable (also known as non-inertial)

of TI displayed. TIB is most appropriate for l Unstable (also known as transient or

fetal ultrasound during the second or third inertial).

trimester pregnancy scan where the highest
temperature increase would be expected
occurring at the soft tissue/bone interface. Stable cavitation (non-inertial)
l TIC – this is the thermal index applied when This form of cavitation is the process where small
scanning cranial bone. Here, the bone is at or micro-bubbles in a medium are forced to oscillate
very near the skin surface. in the presence of the ultrasound. The cavita-
tion bubbles go through phases of expansion
Cavitation effects
and contraction as they oscillate with the vary-
Ultrasound produces an oscillating pressure wave ing ultrasound pressure wave. Generally, this form
which propagates through tissues. This propagat- of stable cavitation is regarded as being safe.
ing pressure wave can cause micro-bubbles within Figure 12.5 graphically demonstrates the phases
tissues to form, grow, oscillate in size and, at suffi- of bubble compression and contraction through
ciently high intensities and pressure, cause these the varying ultrasound pressure wave.

Minimum bubble size Minimum bubble size Minimum bubble size

2 Bubbles collapse Bubbles collapse

in compression in compression

1
Pressure (MPa)

0 Time or distance

–1

–2
Cavitation bubble Cavitation bubble
growth in negative growth in negative
pressure pressure

Maximum Maximum Maximum

bubble size bubble size bubble size

Fig. 12.5 · Demonstrating the phases of bubble compression and expansion through the varying ultrasound
pressure wave. Size of bubble is smallest when compressed during the peak positive pressure and is largest
during the peak negative or rarefaction pressure
96
 Ultrasound safety

Unstable cavitation (transient or inertial)

This type of cavitation has the greatest potential to ......................................................
PRUDENT USE – THE ALARA PRINCIPLE
damage tissue. Here, the intensity of the ultrasound Changes in power output and increased use of
field is high enough to cause the oscillations of the Doppler ultrasound, together with a change in regu-
micro-bubbles to become so great that the bubbles lations governing output, mean that the onus of
collapse, generating high pressures and temperatures safety is placed on the operator. As a consequence,
to the localized area, increasing the potential to cause every measure should be taken to ensure safe practice.
biological damage. This effect has been demon- All ultrasound users should regularly check both
strated in small mammalian animal experiments thermal and mechanical indices while scanning and
causing lung capillary bleeding at pressure thresh- should adjust the machine controls to keep them as
olds of 1 MPa which is well within the diagnostic low as reasonably possible without compromising
range. Although this process has been reported in the diagnostic value of the examination. Where
mammalian experiments, it has not been observed low values cannot be achieved, examination times
in humans. However, knowledge that there is a should be kept as short as possible.
potential risk and hazard for biological damage due The ALARA (‘As Low As Reasonably Achievable’)
to this form of destructive cavitation is especially per- principle should be applied and maintained. Mini-
tinent in early pregnancy where the tissues are more mize any possible risks by minimizing exposure
susceptible to this form of damage. times and exposure intensity.
The use of contrast agents in the form of stabilized

......................................................
gas bubbles increases the probability of cavitation.
GENERAL GUIDELINES
Mechanical index (MI)
There are many safety guidelines issued by several
The mechanical index (MI) is related to the like- national and international ultrasound societies
lihood of cavitation being produced and is defined and organizations to assist all those who use diag-
as the peak rarefactional pressure (Pr) (negative nostic ultrasound so that they are able to make
pressure) divided by the square root of the ultra- informed decisions about ultrasound safety. These
sound frequency: guidelines are based on the best scientific informa-
Peak negative pressure ðPrÞ ðMegapascalsÞ tion available at the time.
MI ¼ pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi A list of these organizations is presented in
Frequency ðMHzÞ
Table 12.3 and further information can be accessed
Equation 2: Formula for calculating mechanical index.
through their Web sites.

The value of Pr (negative pressure) is significant here

and from Equation 2 we can see that the value of MI
is directly proportional to Pr. This means if Pr dou- ORGANIZATION/SOCIETY WEB SITE
bles then MI doubles and, conversely, if Pr is halved
World Federation For Ultrasound http://www.
then MI is halved. Also we can see that frequency is in Medicine and Biology (WFUMB) wfumb.org
inversely related to MI which means as frequency
increases the value of MI actually decreases. European Federation of Societies http://www.
The FDA ultrasound regulations allow a mecha- for Ultrasound in Medicine and efsumb.org
Biology (EFSUMB)
nical index of up to 1.9 to be used for all app-
lications except ophthalmic (maximum 0.23). British Medical Ultrasound Society http://www.
The used range varies from 0.05 to 1.9. (BMUS) bmus.org
It is stipulated that the values of the TI and MI American Institute of Ultrasound http://www.
must be displayed if the ultrasound system is ca- in Medicine (AIUM) aium.org
pable of exceeding an index of 1.
The TI and MI are not absolute values but repre- Australasian Society for http://www.
Ultrasound in Medicine asum.com.au
sent a rough approximation of the risk of creating
certain biological effects. The higher the index Table 12.3 List of ultrasound organizations and societies
value, the higher the potential of a biological effect. which offer safety guidelines
97
12 Ultrasound physics and technology

MACHINE CONTROLS WHICH Stationary Probe

......................................................
INFLUENCE HAZARD The probe should not be held in any fixed posi-
tion for any longer than necessary. Operators
The exposure intensity and therefore any possible
associated temperature rise are affected by many should keep the transducer moving so that specific
operator-dependent controls. The operator should tissues are not subjected to long periods of station-
understand the influence of the machine controls ary beam exposure. Use freeze frame and cineloop
which allow images to be reviewed without
continuing exposure.
Initial Power Setting/Output
Ultrasound machines are normally set up for all
application-specific settings. This sets a default Other Machine Controls
acoustic output which should be adequate to per- The intensity (and temperature rise) is highly
form each examination. Application presets for dependent on other scanner settings such as:
obstetrics should default the machine’s output to l transmitted frequency used
a low setting. The operator should only increase l depth of examination
the output power setting if it is necessary and l focus.
required to improve image quality. The operator should be aware of and monitor
changes to the values of TI and MI in response
Mode of Operation to changes in machine control settings and trans-
ducer combinations.
B mode generally has the lowest power output Table 12.4 summarizes the recommended
and intensity. M mode, color flow imaging, and guidelines issued by the British Medical Ultra-
spectral Doppler have higher outputs which can sound Society (BMUS) in 2000 for thermal and
cause more heating at the site of examination. mechanical indices. Full details of this can be
Examinations should use B mode in the first accessed on their Web site.
instance and employ the use of color and spectral
Doppler only when and if required.
......................................................
EPIDEMIOLOGICAL EVIDENCE
Epidemiology is the study of how often diseases
Exposure Time occur in different groups of people and why.
The overall examination should be kept as short A key feature of epidemiology is the measurement
as possible to obtain the required level of diagnostic of disease outcomes in relation to a population
information. at risk.

BIOLOGICAL EFFECT ACTION BY OPERATOR

MI > 0.3 Possibility of minor damage to Reduce exposure times as much as possible
neonatal lung or intestines
MI > 0.7 Theoretical risk of cavitation Reduce exposure times as much as possible
Risk of cavitation when
conducting contrast agent studies

TI > 0.7 Increased risk of heating Overall exposure time of an embryo or fetus should be restricted
TI > 1 Increased risk of heating Eye scanning not recommended
Overall exposure time of an embryo or fetus should be restricted
TI > 3 Significant risk of heating Scanning of an embryo or fetus not recommended

Table 12.4 Recommended guidelines for values of MI and TI issued by BMUS

98
 Ultrasound safety

As a consequence of the rapid development of However, some of this evidence has been
ultrasound as a diagnostic tool, the general popula- conflicting and the reliability of these outcomes
tion has been and is being exposed to more ultra- has since been questioned.
sound energy than ever before. This is especially To date, diagnostic ultrasound has not been
true for exposures of the fetus. proved to be unsafe in humans. It is important
In the case of ultrasound, epidemiological stud- to note that much of this research work was con-
ies have been used to search for risks associated ducted before output levels were relaxed by the
with previous exposure to diagnostic ultrasound FDA in 1991 and that there is limited data for
of fetuses (in utero) in early pregnancy as it is modern powerful diagnostic equipment using
known that the developing human embryo or fetus Doppler, harmonic imaging, and contrast agents.
is particularly sensitive to the ultrasound beam. Ongoing research into bioeffects is necessary to
The outcomes of published epidemiology re- reaffirm that ultrasound is still a safe modality.
search evidence have suggested associations Continuous vigilance is necessary, particularly
between ultrasound exposure and factors such as in areas of concern such as the use of pulsed
reduced birth weight, delayed speech develop- Doppler in the first trimester.
ment, dyslexia, and non-right handedness.

SUMMARY
· To date, diagnostic ultrasound has not been proved to be unsafe in humans
· Epidemiology data have several limitations:
– Limited data for modern powerful diagnostic equipment
– Ongoing research into bioeffects still necessary
– Using pulsed Doppler, harmonic imaging, contrast agents
· Output regulations relaxed in 1991 for obstetric scans (> 7 times increase)
· Operator responsible for risk/benefit analysis
· Many machine controls have a significant effect
· Displayed MI and TI remove some guesswork for end users
· Knowledge, understanding, and training important
· Prudent use is practiced – ALARA principle
· Many guidelines offered to end users

References
Barnett SB (ed) 1998 Conclusions and recommendations on Medical Ultrasound. Ultrasound in Medicine and Biology
thermal and non thermal mechanisms for biological effects of (special issue) 18
ultrasound. WFUMB (World Federation for Ultrasound in British Medical Ultrasound Society (BMUS) 2000 Guidelines
Medicine and Biology) Symposium on Safety for Ultrasound in for the safe use of diagnostic ultrasound equipment. Online.
Medicine. Ultrasound in Medicine and Biology 24:1–55 Available: www.bmus.org/ultras-safety/us-safety03.asp
Barnett SB, Kossoff G (eds) 1992 Issues and recommendations Henderson J, Whittingham TA, Dunn T 1997 A review of the
regarding thermal mechanisms for biological effects of ultra- acoustical output of modern diagnostic ultrasound equipment.
sound. WFUMB (World Federation for Ultrasound in Medicine BMUS Bulletin 5:10–14
and Biology) Symposium on Safety and Standardisation in

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 Quality assurance and
performance testing
13
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

Introduction 101
1 Discuss the significance of ultrasound
Quality assurance 101 performance testing.
Quality assurance testing 102 2 Explain what an ultrasound test phantom is.
What parameters can be measured? 104 3 List the acoustic properties of ultrasound test
phantoms.
Electrical and mechanical safety 108
4 Explain why there are a number of test
Limitations of ultrasound QA testing 109
phantoms available.
5 Describe a number of performance tests that
can be routinely carried out.
6 List some key limitations of performance
testing.

......................................................
INTRODUCTION
This chapter provides the reader with a general
overview of quality assurance (QA) and perfor-
mance testing of diagnostic ultrasound equip-
ment. Performance testing of pulse-echo imaging
systems will be covered, however because the eval-
uation of Doppler systems is technically more dif-
ficult and is normally performed by specialized
medical physicists, it will not be included in this
chapter.

......................................................
QUALITY ASSURANCE
QA is the process of ensuring that all aspects of
an ultrasound service meet and perform to
agreed standards. The aim of QA is to maintain
standards, and to seek to improve the perfor-
mance of all aspects of an ultrasound service. QA
is an essential aspect of clinical governance as

101
13 Ultrasound physics and technology

it is a risk management tool for ensuring mini- have different operations to perform before produc-
mum standards of practice and performance are ing the images that we see on screen.
attained. This provides reassurance that all The accuracy with which the ultrasound image
patients have access to high-quality ultrasound ser- represents the anatomical area under investigation
vices wherever they are. depends on the correct operation of these compo-
A comprehensive quality assurance programme nents and the accuracy of the various signal and
should consider: image processing functions.
l the quality of the diagnostic investigation Many faults which can develop on ultrasound
l the quality of the patient service scanning equipment are not obvious to the user
l the quality of image production and gradual changes in performance are especially
l the maintenance of equipment. difficult to detect. Quantifiable assessment of a
The quality of the diagnostic investigation and system’s performance is therefore required to
patient service will be affected by factors such as detect any deterioration at an early stage.
operator training/competence and reporting pro- The goal of QA testing is to:
cedures. These aspects will not be discussed here l ensure that an ultrasound system is set up

as this section will concentrate on the quality of correctly and performs to agreed standards
image production specifically relating to the QA l maintain consistency of system performance

assessment and performance testing of diagnostic l provide early detection of problems.

ultrasound machines. The performance assessment and QA of diagnostic

While performance testing in X-ray modalities is ultrasound scanners can also help to:
almost universally practiced, in ultrasound, perfor- l inform the decision making process in the

mance testing remains somewhat controversial for procurement and replacement of equipment
reasons which include: l assess new imaging modalities and signal

l Ultrasound imaging is considered to be an processing techniques.

established and safe modality Ultrasound QA testing should provide objective,
l Modern ultrasound scanners are considered accurate, and repeatable measurement of the image
very stable displayed on the ultrasound screen, i.e. as seen by
l Ultrasound QA testing is often rather the operators. To be successful, QA testing should
subjective be easy to implement, simple to use, and able to
l There are no regulations requiring a QA detect faults at an early stage. It requires the use of
program. strict protocols and documentation in order to
There are currently recommendations from the ensure standardization of procedures.
UK Department of Health and guidance from In the UK, the Institute of Physics and Engineer-
national and international bodies (such as the Insti- ing in Medicine (IPEM) has produced guidelines
tute of Physics and Engineering in Medicine and the for the routine QA of ultrasound imaging systems
American Institute of Ultrasound in Medicine) (see (Price 1995). The IPEM report advocates three
references) as to suggested measures and methods levels of QA testing:
for QA testing. In the UK, only one clinical applica- l Acceptance/baseline tests

tion, breast ultrasound imaging, has any formal l User tests

mandatory requirements for the QA performance l Routine QA tests (carried out by third party).

testing of ultrasound scanning equipment.

Baseline acceptance tests
These tests should be carried out with any new
......................................................
QUALITY ASSURANCE TESTING machine and whenever a new probe or major hard-
ware or software upgrade is added. Typically, it is
Equipment Performance Testing
carried out by a member of the medical physics
Ultrasound images are formed by transmitting and department. It includes all the tests specified for
receiving ultrasound signals which are then pro- routine QA, and establishes baseline readings for
cessed by a number of individual components which further routine and user tests can be
within an ultrasound machine. These components compared.
102
 Quality assurance and performance testing

User tests phantoms have all the required acoustic characteris-

tics matched for soft tissue as indicated above.
These are to be carried out at frequent intervals
The main disadvantage with this type of gel-filled
(between 1 to 4 weeks) by the operator, in order
phantom is that there is a tendency for the gel to
to discover any significant changes in scanner per-
dry out over time which potentially could change
formance over time. It includes a number of sim-
the tissue equivalent acoustic properties.
ple tests which require a minimum amount of
Polyurethane rubber-based phantoms, in com-
time to carry out. These tests relate to the aspects
parison, are very stable and do not need to be
of the scanner function on which users depend
totally enclosed to avoid them drying out. They
for clinically meaningful results and include sim-
can be made to have similar attenuation and scat-
ple checks, such as testing caliper accuracy.
tering properties of soft tissue but have one dis-
Routine QA tests tinct disadvantage in that the speed of sound is
slower, 1450 ms
1 compared to 1540 ms
1 which
These are to be carried out by a third party, typically an ultrasound machine is calibrated to. This dis-
by a member of the medical physics department crepancy amounts to a 6–7% propagation speed
or possibly by a service engineer. They should be error and becomes significant when testing caliper
performed ideally every 6 months but at least every accuracy. The manufacturers have attempted to
12 months. These include a full range of tests which compensate for this by altering the position and
have relevance to normal clinical use and which are distance of the internal targets within the phan-
likely to detect deterioration in performance. tom (positioning them closer together) so that
these urethane phantoms can be used to test cali-
Equipment Required for Image per measurements accurately.
Performance Testing Test phantoms contain a variety of structures
and targets which can be used to test a range of
Tissue equivalent (TE) phantoms
imaging parameters. Figure 13.2 shows a typical
There are a number of commercially available arrangement of targets and structures for a general
ultrasound devices that can be used to test whether purpose test phantom. They contain groups of
an ultrasound system is operating correctly and small nylon wires which can be used to measure
consistently over time. These devices, known as image resolution and test distance accuracy. They
test phantoms, are designed to have similar acous- also contain structures of varying sizes to mimic
tic characteristics to those of soft tissue and should simple cysts. Some have structures which represent
ideally be composed of material which allows: more complicated cysts designed to have a range

1
l sound to travel at a speed of 1540 ms of scattering patterns compared to the background
l attenuation of 0.5–0.8 dB/cm/MHz tissue equivalent medium in order to assess con-
l scattering properties similar to the echogeni- trast resolution and estimate the dynamic range.
city of soft tissue. Ultrasound images are formed using a variety of
The tissue-like attenuation and echogenicity of tis- different transducers which operate over a range of
sue equivalent phantoms allows the testing of frequencies and depths. Therefore ultrasound
ultrasound systems using actual clinical settings. phantoms come in various shapes and sizes to
Commercially available test phantoms are nor- accommodate this. If a low-frequency transducer
mally filled with an aqueous gel or are formed from is to be tested (2–5 MHz) then the test phantom
urethane materials. They contain various targets will need to be relatively large and typically will
and structures designed for testing a number of need to be around 15 cm deep. For higher fre-
parameters. Examples of some commercially avail- quency transducers (7 MHz–12 MHz), where the
able test phantoms are illustrated in Figure 13.1. beam is less penetrating but the images have
Gel-based tissue equivalent phantoms consist of a improved resolution, then a smaller phantom is
closed container filled with an aqueous gel material required with smaller structures to be able to
loaded with graphite particles. These are designed to assess and measure this. Two test phantoms which
scatter ultrasound and produce an image that is sim- are designed for high- and low-frequency trans-
ilar to soft tissue, typically that of the liver. These ducer applications can be seen in Figure 13.3.
103
13 Ultrasound physics and technology

Fig. 13.1 · Examples of some commercially available test phantoms used for ultrasound QA performance
testing (Reproduced with permission of Gammex.)

Arrangement of Horizontal groups of

wires to test wires to test caliper
image resolution accuracy

Cystic
structure
with
varying Fig. 13.3 · Two multi-purpose test phantoms. The
scattering larger phantom on the right-hand side is designed for
properties transducers operating at low frequencies, typically
between 2–5 MHz. The phantom on the left contains
smaller structures and targets with smaller separation
distances to test transducers operating at higher
frequencies, typically above 5 MHz (Reproduced with
permission of Gammex.)

Vertical group of
wires to test caliper
Regions with
anechoic cystic ......................................................
WHAT PARAMETERS CAN BE MEASURED?
accuracy structures There are a number of imaging parameters that can
Fig. 13.2 · Typical arrangement of nylon wire targets, be measured to assess and test the performance of a
simple and complex cysts with a range of scattering diagnostic ultrasound system. The most common,
104 properties within a general purpose test phantom which will be discussed in this chapter, include:
 Quality assurance and performance testing

1 testing measurement accuracy

2 testing image resolution
3 testing depth of penetration (sensitivity)
4 assessing dynamic range.

1. Testing Measurement Accuracy

Taking measurements is an essential part of inter-
preting ultrasound scans and is fundamental to
monitoring and assessing fetal growth, for exam-
ple, and in differentiating normal anatomy from
pathology. Ultrasound machines use electronic
calipers to make measurements of structures to
calculate linear distances, circumferences, and
areas from frozen B-mode images.
Testing the measurement accuracy of a diagnos-
tic ultrasound system can be easily undertaken by
the end user by using an appropriate test phan-
tom. It is usual to assess measurement accuracy
in the vertical and horizontal planes even though
clinically linear measurements can be taken at
any angle within the ultrasound image.
Vertical measurements, which are made along
the axis of the ultrasound beam, are assessed by
acquiring an image of a vertical set of evenly spaced
wires at a known separation within the ultrasound
test phantom. Two of the wires are selected and
the distance is measured using the electronic cali-
pers, as illustrated in Figure 13.4. This electronic
caliper measurement can then be compared to the
known actual distance between the wires and can
be expressed as a percentage error. Fig. 13.4 · Illustrating the assessment of vertical
measurements using a typical tissue equivalent
Horizontal measurements can be assessed by phantom
selecting two targets on a horizontal row of evenly
spaced wires within the test phantom, as illu-
strated in Figure 13.5. Again, the measured dis- either measurement of more than 2% are consid-
tance can be compared with the known actual ered as unacceptable.
distance and expressed as a percentage error using Greater accuracy is achieved by measuring dis-
the simple equation below: tances between two wires which are positioned
furthest apart rather than two which are only a
Percentage error ¼ couple of centimeters apart.
Actual measurement
Electronic measurement Circumference and area measurements are more
 100
Actual measurement difficult to assess and are usually conducted during
routine QA testing which is normally performed
Vertical and horizontal caliper measurements are by a medical physicist rather than the end user.
affected by different factors. Vertical accuracy is Errors of more than 5% should be investigated.
determined by factors such as the speed of sound
within the phantom whereas horizontal measure-
2. Testing Image Resolution
ments are affected by other geometrical factors.
Generally vertical (axial) measurements are more Image resolution, referred to as spatial resolution, is
accurate than lateral measurements. Errors in defined as the ability of an ultrasound system to 105
13 Ultrasound physics and technology

separate images which lie perpendicular or side by

side to the ultrasound beam at the same depth
from the transducer. Lateral resolution depends
on the beam width, focusing characteristics of
the transducer, number of displayed scan lines,
and the system’s sensitivity and gain settings. The
best lateral resolution is achieved at the focal point
where the ultrasound beam is narrowest.
There are two ways of testing axial and lateral
resolution:
a) Object separation method
b) Single wire method.
These tests are normally performed by a medical
physicist rather than the end user.
a) Object separation method
Most test phantoms contain a set of targets at differ-
ent depths designed for the assessment of axial and
lateral resolution which consist of a set of wires
separated by decreasing vertical and horizontal
spacing. An example is illustrated in Figure 13.6.
The spacing of vertical wires to assess axial resolu-
tion decreases from a maximum separation distance
of 2 mm to a minimum separation of 0.25 mm. In
contrast, the spacing of horizontal target wires to
Fig. 13.5 · Illustrating the assessment of horizontal assess lateral resolution is larger, ranging from a
measurements using an appropriate test phantom maximum separation of 5 mm to a minimum sepa-
ration distance of 1.5 mm. This takes into account
that lateral resolution is generally poorer than axial
distinguish two closely spaced targets as separate resolution in most imaging systems.
objects (see Chapter 7 on Resolution). If a system The system’s axial and lateral resolution are
has poor resolution capabilities, small structures determined by identifying the set of two resolvable
lying close to each other will appear as one object, wires with the smallest separation. Figure 13.7
causing incorrect interpretation of the ultrasound shows an image of a test phantom with such an
image. Spatial resolution can be divided into two arrangement of wires. It can be seen that the ultra-
main components in the scan plane, namely axial sound system is able to resolve all targets along
and lateral resolution. the vertical axis (axial plane) but is unable to
resolve targets separated by a distance less than
Testing axial and lateral resolution 2.5 mm across the image (lateral plane).
Axial resolution is the ability of an ultrasound sys- The main disadvantage with this technique is
tem to distinguish two closely spaced targets as that the measurement values are limited to the
separate images along the axis of the ultrasound
5 mm 1.5 mm
beam. Axial resolution depends on the transdu-
cer’s operating frequency, damping characteristics,
and spatial pulse length. Generally, the higher the 2 mm
frequency, the better the system’s axial resolution. 2.5 mm
1 mm
Axial resolution is generally superior to lateral 0.5 mm
0.25 mm
resolution.
Lateral resolution is the ability of an ultrasound Fig. 13.6 · Showing a typical arrangement of wire
system to distinguish two closely spaced targets as spacing to assess axial and lateral resolution
106
 Quality assurance and performance testing

Fig. 13.7 · An image of a test phantom assessing

axial and lateral resolution at a specific depth

spacing of targets within the test phantom and it is

sometimes difficult to decide whether or not a pair
of targets is resolved.
Fig. 13.9 · Assessment of lateral resolution using the
b) Single wire method single wire method
Using this method, any set of target wires can be
chosen. Typically, the vertical set of target wires sometimes difficult to identify and determine the
used to assess vertical distance are ideally suited edges of these blurred target wires.
for this (see Fig. 13.4).
The axial and lateral resolution is measured
indirectly by measuring the length and width of
3. Testing Depth of Penetration (Sensitivity)
individual wire targets at different depths corres- Also known as sensitivity, this is the ability of the
ponding to the transducer’s near, mid, and far ultrasound system to detect and display low-ampli-
field range. Figures 13.8 and 13.9 illustrate this tude echoes and refers to the depth at which the
method for measuring image resolution using a deepest echo signal within an image can be detected
single wire target. and clearly displayed by the ultrasound system.
Using this single wire method, the image of the Clinically, echoes received from small structures
target is magnified using the machine’s zoom con- deep within the tissue are very weak due to the
trol facility to ensure that the errors when taking attenuation of the propagating ultrasound beam.
these small measurements are minimized. The The ability of an ultrasound system to detect, dis-
main disadvantage of this technique is that it is play, and differentiate these weak echoes from
background noise is extremely important in the
interpretation of the ultrasound image.
The point in the image where this is reached is
known as the maximum penetration depth. The
penetration depth is affected by a number of fac-
tors which include:
l output power

l receiver gain

l transducer frequency and efficiency

l focusing

l signal processing within the ultrasound

machine.
Measurement of penetration depth is useful and
should be consistent over time. A loss in penetra-
tion depth, which can lead to a decrease in perfor-
Fig. 13.8 · Assessment of axial resolution using a mance, can indicate a fault in one of the above
single wire method factors.
107
13 Ultrasound physics and technology

For meaningful and comparative assessments, this processing and displayed dynamic range allow ech-
test is performed using exactly the same settings for a oes of varying degrees of amplitude to be displayed
given transducer. These are normally performed in the same image. A broader or wider dynamic range
using a test phantom with the machine operating at yields more shades of gray, while a smaller or nar-
maximum output power and using a deep focal zone rower dynamic range results in a more black and
setting to obtain a measurement of the maximum white or more contrasted appearance of the image.
penetration depth. Figure 13.10 shows a typical The gray scale processing and therefore dynamic
image using the recommended set-up to test the pen- range of an ultrasound system can be assessed by
etration depth. The maximum depth at which scat- using a suitable test phantom which typically con-
tering echoes can be detected and differentiated sists of a group of targets which have varying con-
from background electronic noise is determined trasts relative to the background. An example of a
and measured using the electronic calipers. typical test phantom is shown in Figure 13.11, and
consists of a number of cylinders (which are imaged
4. Assessing Dynamic Range in cross-section) filled with a material of different
scattering strengths to create areas of known and
Dynamic range refers to the way that the gray scale
varying gray levels and echogenicity. Figure 13.12
information is compressed into a usable range for
shows an image using such a phantom to assess a sys-
display on the monitor and is the ratio of the largest
tem’s dynamic range. This is estimated from the dif-
signal to the smallest. This ratio is usually expressed
ference between the brightest and darkest regions
on a decibel scale (dB). Clinically, gray scale
which can be imaged simultaneously.

......................................................
ELECTRICAL AND MECHANICAL SAFETY
Equipment-related physical checks should also be
included in any ultrasound QA testing program
and include regular visual inspection of:

Fig. 13.11 · A typical phantom to test dynamic range

which consists of a range of cylinders filled with
materials of different scattering strengths compared to
the background material

Fig. 13.10 · Measurement of penetration depth.

Electronic caliper indicates the maximum penetration Fig. 13.12 · Ultrasound image using such a test
depth determined by the operator phantom to assess dynamic range

108
 Quality assurance and performance testing

l transducers, for cracks and delamination in subjective and difficult to quantify. To obtain opti-
the plastic housing mum and reproducible results, it is important to
l cables, for any loose and frayed electrical take a rational and consistent approach to the ultra-
cables sound system’s settings.
l peripherals A straightforward approach adopted by the end
l air filters, ensuring that they are clean and user should include some basic tests such as checking
not obstructed. caliper accuracy and measuring the depth of penetra-
tion, for example. These are extremely useful to mon-
itor the performance of an ultrasound system.
LIMITATIONS OF ULTRASOUND Recent developments in technology leading to
......................................................
QA TESTING the use of higher frequency transducers with
A substantial effort has been made to determine the improved image resolution, for example, have
most appropriate and clinically relevant tests, with improved the performance of ultrasound equip-
recommendations by many professional bodies ment to such an extent that many machines are
who have published general guidelines describing now able to resolve targets on current phantoms
standard methods for measuring the performance easily. There is therefore a growing need for a
of ultrasound systems. These outline the most new generation of test phantoms in order to mea-
appropriate imaging tests, i.e. parameters that sure adequately the capabilities of new equipment.
should be tested, the frequency of this testing, and Further developments in ultrasound perfor-
the most appropriate phantoms to use. However, mance testing and phantoms are necessary and
there are many machine controls and variables that should lead to a standard practice of QA in all
must be considered which, on modern ultrasound ultrasound departments in the future. As end users,
systems, are difficult to individually control without we need to ensure that the equipment we use is
affecting each other. This makes a clinically mean- adequate and appropriate to ensure high-quality
ingful assessment regarding the performance of diagnostic ultrasound imaging is achieved and
the ultrasound system using test phantoms maintained.

SUMMARY
· Test phantoms are made to contain various tissue equivalent materials
· Phantoms come in a variety of shapes and sizes
· Phantoms are utilized for a range of QA performance testing
· The guidelines for ultrasound QA performance testing programs are currently descriptive rather than
prescriptive
· Maintaining an ultrasound QA testing program is straightforward and is effective in identifying deficiencies
· Guidelines need to be updated periodically as ultrasound technology develops

References
Price R (ed) 1995 Institute of Physics and Engineering in
American Institute of Ultrasound in Medicine 1995 Quality
Medicine Report 71: Routine quality assurance of ultrasound
assurance manual for gray scale ultrasound scanners (Stage 2).
imaging systems. IPEM, York
AIUM, Laurel, Maryland

109
13 Ultrasound physics and technology

Further reading Madsen E (ed) 1995 Quality assurance manual for gray scale
ultrasound scanners (Stage 2). AIUM, Laurel, Maryland
American College of Radiology 1999 ACR Technical standard
Medical Devices Agency 1999 Evaluation Report MDA/98/52.
for diagnostic medical physics performance monitoring of real
HMSO, London
time B-mode ultrasound equipment. ACR, Reston, Virginia
Goodsitt MM, Carson PL, Witt S et al (eds) 1998 Report of
AAPM Ultrasound Task Group No 1: Real-time B-mode ultra-
sound quality control test procedures. Medical Physics 25
(8):1385–1406

110
 New technology and recent
advances in ultrasound
imaging
14
......................................................................................................................................

CONTENTS
LEARNING OBJECTIVES

1 Explain the principles behind the advances in

Digital beam forming 111
technology described.
High-frequency imaging 112
2 Describe the advantages of the advances in
Extended field of view imaging 112 technology.
Compound imaging 112 3 Describe any disadvantages in introducing the
new technology.
Three-dimensional imaging 112
4 Give examples of clinical applications of new
Harmonic imaging 115 technology.
Contrast agents 116
Pulse inversion imaging 116
Elastography 117 In this chapter we shall look at some of the inno-
vations in ultrasound imaging that have been
Tissue characterization 118
introduced in the last five to ten years, and also
Tissue motion 118 some of the new technology which is still at the
Portable ultrasound machines 118 research and development stage.

......................................................
DIGITAL BEAM FORMING
The beam former is the system of electronics that
determines the shape of the beam. Earlier beam
formers used either analog electronics or a combi-
nation of analog and digital electronics. In mod-
ern transducers the beam former is totally digital
which enables the ultrasound beam to be focused
with greater precision.
The amount of focusing and the position of
the focus in an ultrasound beam is a function
of the beam former. Focusing is achieved by apply-
ing delays to the inner elements of the group of
crystals that are used to produce a composite ultra-
sound pulse and to receive echoes from the sub-
ject. Accurate timing of these delays is critical in
producing a narrow beam focusing at the correct
depth. In addition, the more accurate the timing
of the delays, the less noise is produced and the
better the contrast resolution.

111
14 Ultrasound physics and technology

Using analog beam formers, it is not possible to obtained by sliding the probe over the area of
produce delay timers with the accuracy required interest and as the images are acquired they are
and this limits their performance. However, beam ‘stitched together’ electronically (Fig. 14.1). The
formers are now produced using digital electronics result is a single slice image covering the whole
for the time delays. In addition to producing nar- area of interest, for example a full length view
rower beams, digital beam formers can operate at of the Achilles tendon (Fig. 14.2). Image feature
higher frequencies and can be used with broad- recognition software is used to combine images.
bandwidth transducers. This feature is now standard on most current
ultrasound systems, and is particularly beneficial
where large areas of the patient need to be visua-
......................................................
HIGH-FREQUENCY IMAGING lized on one image, such as obstetrics or musculo-
High-frequency ultrasound imaging using frequen- skeletal imaging.
cies above 20 MHz is being developed to enable
the imaging of superficial structures at a very high
resolution. Using conventional medical ultrasound ......................................................
COMPOUND IMAGING
at 5 MHz, it is possible to penetrate up to 20 cm This technique combines electronic beam steering
and achieve a spatial resolution of 0.5–1.0 mm. with conventional linear array technology to pro-
However, with high-frequency ultrasound it is duce real-time images acquired from different view
possible to image with a resolution of 50 microns angles (see Fig. 14.3) Between 3 and 9 sector images
(1/20 mm). The disadvantage is that because the are rapidly acquired and combined to produce a
attenuation is increased at high frequencies, pene- compound real-time image (see Fig. 14.4). Com-
tration is reduced to a few millimeters. pound imaging improves image quality by reducing
The initial clinical applications of high-frequency speckle, clutter, and other acoustic artifacts. It also
ultrasound include the anterior chamber of the eye, gives better definition of the boundaries of structures.
intravascular ultrasound of arterial walls, skin, and Because of the improved contrast resolution, com-
cartilage. pound imaging may be useful for the breast, periph-
eral blood vessels, and musculoskeletal applications.

......................................................
EXTENDED FIELD OF VIEW IMAGING
This is an imaging process which combines static ......................................................
THREE-DIMENSIONAL IMAGING
B-mode techniques with real-time imaging so that In conventional two-dimensional imaging the
a large subject area can be viewed on a single static operator integrates a large number of images
image. Extended field of view (FOV) images are representing slices of the subject to form a mental

Transducer movement

Images stitched together electronically

Fig. 14.1 · Diagram showing how images of the subject are acquired before being electronically ‘stitched together’
112
 New technology and recent advances in ultrasound imaging

a 3-D image which can be reviewed after the exam-

ination by the operator and also by other staff
and patients. With 3-D ultrasound, an image of
the surface of a structure is produced; this can be
rotated through different planes and the surface
viewed from many angles. It is also possible for
the operator to ‘peel away’ layers of a 3-D image
and see inside the structure.

3-D Imaging Technology

The production of a 3-D image requires a volume
of tissue to be scanned. The data from this vol-
ume are then used to construct the types of image
Fig. 14.2 · Extended field image showing the full required. There are three approaches to scanning a
length of the Achilles tendon volume of tissue: free-hand, mechanical, and elec-
tronic scanning.
Linear array Linear array Linear array
Free-hand 3-D imaging
transducer transducer transducer
In this approach the operator sweeps the probe
across the volume of interest and a series of scan-
ning planes are recorded according to their posi-
tion on the patient (see Fig. 14.5). In order to
register these planes, a method of determining
the position of the transducer in space is required.

Fig. 14.3 · Diagram showing how electronic beam

steering is used to acquire images from different angles

Linear array
transducer

Probe
movement

Fig. 14.4 · Diagram showing how the images are

combined to produce a compound real-time image

3-D image of the subject’s anatomy; however this

mental 3-D picture is only available to the opera-
tor and only during the scanning process. The Fig. 14.5 · In free-hand 3-D imaging the operator
challenge for equipment designers is to produce sweeps the probe across the volume of interest
113
14 Ultrasound physics and technology

This can be achieved by using a receiver in the

probe which will detect a magnetic field generated
by a transmitter situated next to the couch (see
Fig 14.6). Each image slice will have image infor-
mation and position information for use in 3-D
construction. Another method of determining the
position of the scan plane is to use a radio transmit-
ter and radio detection coils attached to the probe.
The advantage of free-hand 3-D imaging is that
a large volume can be scanned, however consider-
able skill is required and any measurements made
are not as accurate as the automated scanning
methods.

Mechanical 3-D imaging

In a mechanical system the probe is attached to a
motor which mechanically oscillates in a sector
Fig. 14.7 · Diagram showing how the probe oscillates
movement at right angles to the imaging plane in a sector movement to scan a volume of tissue
(see Fig. 14.7). A volume of tissue is scanned with
2-D image data collected at regularly spaced inter-
vals and stored for 3-D construction. In addition
to the sector volume already described, parallel Gantry
slice volumes (see Fig. 14.8) and rotational slice
volumes are also available. The parallel slice
method gives the most accurate reconstruction
because the slices are equally spaced; however Probe
the scanning mechanisms are more bulky than movement
the sector and rotational methods. With the sector
and rotational volume methods, the separation
between the slices increases with distance from
the axis of rotation causing a decrease in resolu-
tion and less accurate 3-D reconstruction.

Magnetic field
detector
Fig. 14.8 · Diagram showing how a parallel slice
volume is scanned in mechanical 3-D imaging

Magnetic field Electronic 3-D imaging and 4-D imaging

generator
This approach makes use of a transducer with a
2-D array (see Fig. 14.9) with the data being col-
lected from a pyramid shaped volume. This type
of transducer may have over 2000 elements and
collects the data from each image plane simulta-
Fig. 14.6 · The position of the transducer is determined neously. This enables the transducer to scan over
by scanning within a magnetic field. A receiver in the 20 volumes per second and produce real-time 3-D
transducer detects the magnetic field images – this is known as 4-D imaging.
114
 New technology and recent advances in ultrasound imaging

Transducer
with 2-D array

Transmission
frequency f1
2-D array

Frequency
Fig. 14.11 · Diagram showing the transmitted
frequency spectrum (fundamental frequency)
compared with the total range of frequencies
available to the broad bandwidth transducer
Fig. 14.9 · Diagram showing a transducer with a 2-D
array of piezoelectric elements, which collects data
from a pyramid shaped volume

......................................................
HARMONIC IMAGING
The aim of this method of ultrasound imaging is to Reception frequency f1 + f2
reduce haze or scatter, and produce a cleaner image
with higher contrast resolution. This technology
takes advantage of a process known as non-linear
Frequency
propagation where ultrasound transmitted at the
fundamental frequency is transferred into the har- Fig. 14.12 · Diagram showing the frequency
monic frequencies. For example, if the fundamen- spectrum detected by the transducer
tal frequency is 3 MHz, some of the energy would
be transferred to the second harmonic (6 MHz)
and third harmonic (9 MHz) frequencies, and to
higher harmonics.
In harmonic imaging a broad bandwidth trans-
ducer (see Fig. 14.10) is used to transmit ultrasound
4 MHz
at the fundamental frequency (see Fig. 14.11) and
detect echoes at both the second harmonic and fun-
damental frequencies (see Figs 14.12 and 14.13). 4 MHz + 8 MHz

Fig. 14.13 · The transducer transmits fundamental

frequency ultrasound and receives both fundamental
frequency and 2nd harmonic frequency ultrasound
Broad bandwidth transducer
transmits a wide range of
frequencies and is sensitive However, the signals produced by the fundamental
to a wide range of frequencies
frequency are filtered out and not used to form the
image (see Fig. 14.14). The advantage of this
Frequency method of imaging is that the second harmonic
Fig. 14.10 · Frequency spectrum of a broad bandwidth frequency contains the high amplitude echoes
transducer, which shows the range of frequencies the which arise from the axis of the beam whereas the
transducer is able to transmit and the range of fundamental frequency contains the low amplitude
frequencies it is sensitive to artifactual echoes and these are filtered out.
115
14 Ultrasound physics and technology

enhanced by the bubbles in a sound wave resonat-

ing (oscillating) at a specific frequency according
to their diameter and therefore acting as a pro-
ducer as well as a reflector of sound. This fre-
quency is in the MHz range, approximately the
Fundamental 2nd harmonic same as the transducer frequency, and is therefore
frequency f1 frequency f2 detected by the transducer.
filtered out Ultrasound contrast agents are used in a variety of
clinical situations such as cardiovascular imaging to
Frequency
image blood vessels; gynecological imaging to image
Fig. 14.14 · Diagram showing the fundamental the uterine cavity and patency of the fallopian tubes;
frequency spectrum filtered out leaving the and to quantify the flow characteristics through an
2nd harmonic frequency spectrum for producing the
organ or tumor by producing wash-in/wash-out
image
curves. Many of these examinations are now in rou-
tine use within many departments, and greatly
assisting in the diagnosis of a range of conditions.
Higher acoustic power is required and, because
of the narrower range of frequencies used for
image formation, pulse lengths are longer than in
Targeted Micro-bubbles
fundamental imaging. This results in poorer axial Targeted micro-bubbles are being developed,
resolution. which have special characteristics which bind
This method of imaging is advantageous when them to certain cells such as inflamed cells or can-
scanning through large depths of tissue and is also cer cells. The aim is to develop a non-invasive
used in conjunction with micro-bubble contrast method of imaging diseased organs. Work is also
agents. The facility is now available on most sys- being carried out to research the possibility of
tems, however it may prove beneficial to de-acti- using these targeted micro-bubbles to deliver
vate the function during certain examinations drugs or genetic material, by disrupting them
when no perceivable benefit is obtained. when they reach areas of pathology.

......................................................
CONTRAST AGENTS Contrast Agents and Harmonic Imaging
Contrast agents are used in medical imaging to When micro-bubbles are insonated they resonate
increase contrast and make organs, vessels, and at their fundamental frequency and also at their
body cavities easier to see. In medical ultrasound second, third, and higher harmonic frequencies.
contrast agents containing micro-bubbles have By using harmonic imaging tuned to the second
been found to give the highest contrast. harmonic frequency of the micro-bubbles, it is pos-
The micro-bubbles consist of air or inert gas sible to discriminate between the micro-bubbles
encapsulated in a layer of protein or polymer. This and tissue. This technique increases the contrast
layer prevents the bubbles dissolving too rapidly between the micro-bubbles and normal tissue.
in blood or coalescing to form larger bubbles. The contrast can be further enhanced by using
The micro-bubbles are typically 3 mm in diameter, pulse inversion imaging – see below.
a similar size to red blood cells, and can therefore

......................................................
be transported into the smallest capillaries and
PULSE INVERSION IMAGING
across the lungs. It is important that they can sur-
vive the passage across the lungs because this This imaging modality is used to increase the sen-
enables imaging of the arterial system using a sitivity of ultrasound to contrast agents. In conven-
venous injection. tional B-mode or harmonic imaging, only one
The micro-bubbles produce strong scattering pulse of ultrasound at a time is transmitted. In
because of the large acoustic impedance difference pulse inversion imaging, two pulses are transmit-
at the gas/blood interface. This scattering is further ted, the second being an inverted copy of the first
116
 New technology and recent advances in ultrasound imaging

Pulse 1 Pulse 2 bubbles are moving slowly, and therefore do not

move far between successive transmitted pulses.
An advantage of pulse inversion imaging over
harmonic imaging is that it is possible to use a wide
Pulses 180º out of phase
range of frequencies for transmission and detection
of ultrasound. This results in a shorter pulse length
Fig. 14.15 · Diagram showing two pulses being and therefore improved axial resolution.
transmitted from the transducer, the second pulse
being an inverted copy of the first pulse

one (see Fig. 14.15). When the echoes from these

......................................................
ELASTOGRAPHY
Elastography is the measurement of the elastic
two pulses are detected by the transducer they are
properties of tissue, and ultrasound can be used
added together.
for this purpose. It uses echo information to pro-
Echoes reflected from normal tissues cancel
duce a 2-D display of the elasticity (stiffness) of
each other out when they are added after detection
tissues scanned. The elasticity of tissue is deter-
(see Fig. 14.16). However, echoes from micro-
mined by applying stress, and measuring any asso-
bubbles do not cancel each other out because of
ciated movement. The stiffness of the tissues is not
the harmonic frequencies produced by the bub-
necessarily related to its backscatter properties,
bles (see Figs 14.17 and 14.18). This results in an
and may therefore result in contrast between tis-
ultrasound image where the contrast produced by
sues which is not apparent with conventional
the micro-bubbles is significantly enhanced. It is
ultrasound imaging. Software in the ultrasound
particularly useful in small vessels where the
machine measures the degree of compression of
tissue and calculates the elasticity.
Echo 1 Echo 2 Sum
The main application of elastography is in dif-
ferentiating between benign and malignant tissue,
+ = malignant tissues being less elastic and therefore
harder to compress than benign tissue. This tech-
Echoes 180º out of phase nique has been used to look at breast tumors,
Fig. 14.16 · Diagram showing how echoes reflected where the tumor is imaged by ultrasound before
from normal tissues cancel each other out when they and after compression by the probe. Elastography
are added has also been used to examine prostate tumors

Micro-bubbles

Pulse 2 Pulse 1

Pulses 180⬚ out of phase

Echoes from bubbles including harmonics

Fig. 14.17 · Diagram showing echoes reflected from micro-bubbles (these echoes include some harmonic
frequencies)
117
14 Ultrasound physics and technology

......................................................
Sum
TISSUE MOTION
Echo 1 Echo 2
Conventional B-mode ultrasound scanning will
provide information on overall tissue motion.
+ =
To obtain more information on internal tissue
motions of organs, a method known as Doppler
Echoes not completely out of phase
tissue imaging (DTI) has been developed. This is a
Fig. 14.18 · Diagram showing how the echoes from
variation of color Doppler imaging and can be
micro-bubbles, because they are not completely out of implemented using a decreased wall thump filter
phase, result in a high-amplitude signal when added to record low velocities and decrease signals from
the movement of blood, in order to retain only
and the elasticity of arterial walls; however the the stronger tissue signal in the image. The tech-
technique is still in its infancy and is largely used nique is still in the research phase, but has the
as a research tool. potential to provide useful information in the diag-
nosis of pathology of organs, particularly the heart.

......................................................
TISSUE CHARACTERIZATION
Tissue characterization using ultrasound has been ......................................................
PORTABLE ULTRASOUND MACHINES
the goal of scientists for many years. If successful Portable machines have been available since the
it would produce quantifiable information about mid 1990s. These machines were similar in size
the type of tissue being imaged, similar to the to a portable television set and were fairly limited
Hounsfield units obtained during computerized in the range of applications offered and their per-
tomography (CT) scanning. The aim is to analyze formance. However, the advances in flat screen
the signals received from different tissues and and microprocessor technology has meant that
characterize them according to their acoustic prop- there are now laptop machines which have a range
erties. However, the transmitted pulse and the ech- of applications and image quality approaching
oes from the site of interest are affected by the that of conventional scanners. In addition to this
intervening tissue, which gives a distorted signal there are inexpensive handheld scanners which
and, until this problem is dealt with satisfactorily, have applications in emergency investigations
tissue characterization will remain the subject of such as FAST (focused abdominal sonography for
research. trauma) scanning.

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 New technology and recent advances in ultrasound imaging

SUMMARY
· Digital beam forming improves lateral resolution by accurately focusing the ultrasound beam
· High-frequency imaging uses frequencies above the normal diagnostic range (above 20 MHz) to produce very
high resolution ultrasound images of superficial structures
· Extended field of view is an ultrasound technique which enables the operator to produce a static image of a
large section
· Compound imaging improves contrast resolution by scanning from multiple view angles
· Three approaches to 3-D scanning are described: free hand, mechanical, and electronic scanning. With electronic
scanning it is possible to produce real-time 3-D images
· Harmonic imaging reduces haze and scatter when scanning large patients. This is achieved by using only second
harmonic frequency echoes to produce the image
· The main contrast agent used in ultrasound imaging is a solution containing micro-bubbles of air or inert gas.
These micro-bubbles are of a similar size to red blood cells, which enables them to cross the lungs. This enables
them to be used for arterial studies using a venous injection
· The visualization of contrast agents can be improved by using harmonic imaging or pulse inversion imaging
· Elastography is a technique under development, which attempts to distinguish malignant tissue from normal
tissue by measuring the amount that a structure distorts under pressure. Ultrasound imaging is used to make
the measurement
· The aim of tissue characterization is to analyze the signals received from different tissues and characterize them
according to their acoustic properties. This technology is still in the research stage with many difficulties to
overcome
· Tissue motion imaging is a development of color Doppler and is used to look at the movement of tissues within
body organs such as the heart
· Portable ultrasound machines have undergone major improvements over the last 10 years and the better
machines perform almost as well as conventional scanners

119
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 Multiple choice questions and
answers

......................................................
MULTIPLE CHOICE QUESTIONS
Select all the correct answers in the following:
15
......................................................................................................................................

c. Matter must be present for transmission

d. Molecular compression and rarefaction
occur
The Ultrasound Beam
6 When two or more (plane) ultrasound waves
1 An ultrasound beam passing through the body exist in the same medium at the same time
a. is attenuated a. they will interfere constructively if traveling
b. produces heating of tissues with the same direction and phase
c. can be reflected b. standing waves will be produced if they are
d. produces ionization traveling with the same direction and phase
c. standing waves will be produced if they are
2 Ultrasonic pulses
traveling in the same direction but out of
a. are poorly transmitted by liquids
phase
b. are poorly transmitted by air gaps
d. None of the above
c. are partially reflected at interfaces between
two liquid media 7 Specific acoustic impedance as applied to
d. are partially transmitted at interfaces diagnostic ultrasound increases with
between two solid media increasing
a. frequency
3 The Fraunhofer zone is the
b. wavelength
a. image plane
c. mass
b. image focus
d. density
c. near field
d. far field 8 When the diagnostic ultrasound beam is inci-
dent on the surface separating different tissues
4 Which of the following statements are true
a. none of the beam will be transmitted
concerning the nature of diagnostic ultrasound
b. none of the beam will be reflected
in liver?
c. reflection can occur when the beam is at
a. The wave speed and frequency are constant
right angles to the interface
regardless of the wavelength
d. when incident at greater than the critical
b. The wave speed is constant regardless of the
angle, there will be total transmission
wavelength
c. Wave speed increases with the increasing 9 When an acoustic wave is transmitted through
frequency soft tissue
d. None of the above a. there will be no reduction in intensity
b. attenuation will occur
5 Which of the following characteristics of diag-
c. energy will be transmitted by way of ioni-
nostic ultrasound applies also to X-radiation?
zation and excitation
a. It is a wave phenomenon
d. energy will be transmitted by way of
b. Its wave speed and frequency are inversely
Compton scattering
proportional

121
15 Ultrasound physics and technology

10 When an ultrasound beam is attenuated while 17 Acoustic reflectivity

passing through tissue a. is determined by acoustic impedance at an
a. a 3 dB loss is equivalent to a 50% reduction interface
in intensity b. equals 100 if Z1 ¼ Z2
b. a 6 dB loss is equivalent to a 100% c. is higher for an air–soft-tissue interface than
reduction in intensity a bone–soft-tissue interface
c. the normal rate is 10 dB/cm/MHz d. increases with increasing frequency
d. 90% reduction of the original intensity is
18 An ultrasound wave may be described as
equivalent to a 90 dB loss
a. a longitudinal pressure wave
11 When a transmitted ultrasound beam b. a transverse wave
changes direction across an interface, this c. being formed by particle oscillations
is called d. changes in electrical properties of tissues
a. reflection
19 Ultrasound used for diagnosis
b. defraction
a. has a frequency in the region 2 to 10 kHz
c. refraction
b. has a velocity in air of 1500 ms-1
d. scattering
c. will not travel through a vacuum
12 Ultrasound and X-rays differ in which of the d. is produced and detected by a transducer
following ways?
20 Ultrasound has the following properties. It
a. One is transverse, the other longitudinal
a. can be deflected by a magnetic field
b. One requires matter, the other does not
b. is attenuated in tissue
c. One has constant wave speed, the other
c. has a sinusoidal wave form
variable wave speed (in soft tissue)
d. can travel through water
d. All of the above
21 An ultrasound beam is attenuated
13 Diagnostic ultrasound intensity is often
a. by reflection at a tissue interface
measured in
b. and causes ionization of atoms
a. W/cm2
c. by scattering
b. grays
d. by absorption in tissues
c. rad
d. decibels 22 Greater than 50% energy reflection will take
place at a
14 Intensity is equal to
a. soft-tissue–bone interface
a. power/area
b. water–soft-tissue interface
b. area/power
c. soft-tissue–gas interface
c. amplitude/distance
d. muscle–fat interface
d. frequency/wavelength
23 The magnitude of the reflected signal
15 Diagnostic ultrasound intensity
a. decreases as the angle of incidence
a. increases with increasing frequency
approaches 90 degrees
b. is a measure of particle displacement in
b. depends on the change of acoustic
the conduction medium
impedance at an interface
c. is measured in mW/cm2
c. is independent of the acoustic
d. is the same as ultrasound power
impedance
16 As ultrasound is transmitted through tissue, d. depends on the frequency of the beam
its intensity decreases because of
24 Interference phenomena
a. excitation
a. may occur when two waves interact
b. absorption
b. are more common with continuous wave
c. scattering
ultrasound
d. divergence

122
 Multiple choice questions

c. always produce a wave form of reduced c. is temperature dependent

amplitude d. is equal for muscle and bone
d. may be of value to ultrasound
33 The velocity of an ultrasound beam may be
25 Acoustic impedance depends on determined by measuring the
a. the intensity of the ultrasound beam a. time taken for a pulse to be returned
b. the elasticity of the tissue through a Perspex block of a known
c. tissue density thickness
d. tissue temperature b. time taken for a pulse to be returned
through a known depth of water
26 In which of the following materials is the
c. reflection of the beam by a wire mesh
speed of ultrasound greatest?
placed in water
a. Air
d. distance between peaks of the wave
b. Bone
form
c. Water
d. Soft tissue 34 The propagation speed of sound through soft
tissue is
27 What is the wavelength of a 5 MHz ultrasound
a. 1450 ms-1
pulse in soft tissue?
b. 1650 ms-1
a. 0.3 mm
c. 1540 ms-1
b. 0.5 mm
d. 1230 cms-1
c. 3 mm
d. 5 mm 35 Given the various physical characteristics of
ultrasound, then it is true that
28 As frequency increases
a. its speed is the same in all materials
a. wavelength increases
b. its speed does not depend on its frequency
b. imaging depth decreases
c. its speed depends on the density of the
c. propagation speed decreases
supporting medium
d. a and b
d. its speed increases with frequency
29 The frequency of a sound wave is
36 Lateral resolution can be improved by
determined by
a. damping
a. the media through which it travels
b. pulsing
b. its propagation
c. focusing
c. its source
d. reflecting
d. reflection
37 Axial resolution can be improved by
30 As frequency increases, the attenuation coefficient
a. damping
a. decreases
b. pulsing
b. increases
c. focusing
c. stays the same
d. increasing operating frequency
d. attenuation coefficient not affected by
frequency 38 The resolution of an ultrasound beam may
be determined by
31 Which of the following sound frequencies
a. imaging a series of wires at varying depth
would include diagnostic ultrasound?
from the transducer face
a. 10 Hz
b. imaging a series of wires all the same depth
b. 10 kHz
from the transducer face
c. 100 kHz
c. compound scanning around a
d. 10 MHz
Perspex block containing a single central
32 Velocity of ultrasound wire
a. depends on the transmitted frequency d. linear scanning of a single wire in a
b. varies for different materials water bath
123
15 Ultrasound physics and technology

39 The lateral resolution of the diagnostic 5 The active elements of the diagnostic
ultrasound system is ultrasound transducer
a. also called the azimuthal resolution a. may be crystalline material
b. determined by the slice thickness b. operate on the basis of the photoelectric
c. better with higher frequency effect
d. better than axial resolution c. convert electrical energy into mechanical
energy
40 The axial resolution of a transducer is primar-
d. convert mechanical energy into electrical
ily determined by
energy
a. spatial pulse length
b. the transducer diameter 6 The principle on which the ultrasound
c. the acoustic impedance of tissue transducer operates is the
d. density a. photoelectric effect
b. crystalline effect
41 The lateral resolution of a transducer is pri-
c. piezoelectric effect
marily determined by
d. transducer effect
a. spatial pulse length
b. the beam width 7 A piezoelectric crystal may be made of
c. the acoustic impedance of tissue a. aluminum
d. applied voltage b. calcium tungstate
c. quartz
d. lithium fluoride
The Transducer 8 Best image resolution is obtained
1 The fundamental operating principle of a. at the transducer surface
medical ultrasound transducers is b. in the near field
a. Snell’s law c. in the far field
b. ALARA principle d. in the focal zone
c. piezoelectric effect 9 Crystals for ultrasound transducers are
d. impedance effect composed of
2 Which one of the following quantities varies the a. sodium iodide
most with distance from the transducer face? b. quartz
a. Axial resolution c. barium titanate
b. Lateral resolution d. lead zirconate titanate
c. Frequency 10 The backing material in the transducer is
d. Wavelength a. rubber
3 What determines the transducer frequency b. lead rubber
selection for diagnostic ultrasound? c. resin loaded with metal
a. Intensity and resolution d. plastic
b. Intensity and propagation speed 11 The acoustic insulator in a transducer
c. Scattering and impedance a. is a safety device
d. Resolution and penetration b. reduces ‘ringing’
4 Which of the following improves sound c. is the main factor in shortening the pulse
transmission from the transducer element into length
the tissue? d. absorbs ultrasound
a. Matching layer 12 Phased array transducers
b. Doppler effect a. have elements which emit ultrasound
c. Damping material independently
d. Coupling medium b. may be used to alter the beam direction

124
 Multiple choice questions

c. are used only on real-time scanners 4 The TGC control compensates for
d. have a variable frequency a. focusing
b. machine instability
13 A linear array transducer
c. transducer aging
a. has multiple elements of the same
d. attenuation
piezoelectrical material
b. can be used to produce real-time images 5 Ultrasound is used in diagnosis to
c. always has a frequency of 3.5 MHz a. produce dynamic images of physiological
d. does not employ a coupling medium functions
b. demonstrate soft-tissue structures
14 Bandwidth
c. monitor heart valve movement
a. indicates the range of frequencies present
d. produce three-dimensional images
b. is related to the pulse length
c. is fixed for a particular transducer 6 Scan converters
d. is mainly determined by patient size a. are used only with conventional B scanners
b. may be either analog or digital
15 A coupling medium
c. employ an electron gun and deflection
a. is always used between the transducer and
system
the patient’s skin
d. increase the gray scale of the image
b. is only used to help the transducer slide
over the surface, thus reducing friction 7 The dynamic range of an ultrasound system
c. eliminates air, thereby allowing maximum a. is expressed in decibels
transmission of the beam b. is a measure of resolution
d. must be a water-soluble gel c. expresses the range of the signal amplitudes
that can be recorded
d. depends mainly on the frequency
Instrumentation employed

1 The dynamic range of an ultrasound system is 8 Artifacts in B scanning can be caused by

defined as a. reverberation
a. the speed with which ultrasound b. refraction
examinations can be performed c. misregistration
b. the range over which the transducer can be d. room temperature changes
manipulated
c. the ratio of the maximum to the minimum
intensity that can be displayed Doppler
d. the range of pulser voltages applied to the
1 The Doppler effect
transducer
a. measures the change in frequency of
2 The operation of the signal processor that ultrasound
reduces noise is b. results from the movement of interfaces
a. filtering c. may be used to determine blood vessel
b. TGC patency
c. scan conversion d. is always detected in audible sound
d. compression
2 The Doppler shift frequency
3 Increasing the gain generally produces the a. depends on acoustic impedance
same effect as b. is independent of the direction of
a. decreasing the attenuation movement of the interface
b. increasing the compression c. detected, will be greater at 5 MHz than at
c. decreasing output power 2 MHz
d. increasing the output power d. is normally detected by a single transducer

125
15 Ultrasound physics and technology

3 The Doppler shift frequency is 2 Doses to the patient undergoing ultrasound

a. inversely proportional to the velocity of examinations are increased
movement of an interface a. if the pulse repetition frequency is
b. directly proportional to the pulse repetition increased
frequency b. if the intensity is reduced and the gain is
c. inversely proportional to the velocity of increased
ultrasound in a medium c. when deeper organs are being visualized
d. dependent on the transmitted frequency d. if the dynamic range is increased
3 In the exposure of the tissues to ultrasound
Safety a. the units of intensity are mW/cm2
1 Ultrasound beams may produce b. the unit of ultrasound dose is the rad
a. cooling of the tissues c. if the beam is said to have a 30 dB gain, that
b. cavitations means it is 30% more intense than the
c. cavitations independent of the frequency used reference beam
d. streaming d. if the reflected ultrasound beam is 40 dB,
it is only 0.1% of the transmitted beam

126
 Multiple choice answers

......................................................
b. standing waves will be produced if they
MULTIPLE CHOICE ANSWERS
are traveling with the same direction and
phase
The Ultrasound Beam c. standing waves will be produced if they are
1 An ultrasound beam passing through the traveling in the same direction but out of
body phase
a. is attenuated d. None of the above
b. produces heating of tissues 7 Specific acoustic impedance as applied to
c. can be reflected diagnostic ultrasound increases with
d. produces ionization increasing
2 Ultrasonic pulses a. frequency
a. are poorly transmitted by liquids b. wavelength
b. are poorly transmitted by air gaps c. mass
c. are partially reflected at interfaces between d. density
two liquid media 8 When the diagnostic ultrasound beam is
d. are partially transmitted at interfaces incident on the surface separating different
between two solid media tissues
3 The Fraunhofer zone is the a. none of the beam will be transmitted
a. image plane b. none of the beam will be reflected
b. image focus c. reflection can occur when the beam is at
c. near field right angles to the interface
d. far field d. when incident at greater than the critical
angle, there will be total transmission
4 Which of the following statements are true
concerning the nature of diagnostic ultrasound 9 When an acoustic wave is transmitted through
in liver? soft tissue
a. The wave speed and frequency are constant a. there will be no reduction in intensity
regardless of the wavelength. b. attenuation will occur
b. The wave speed is constant regardless of c. energy will be transmitted by way of
the wavelength ionization and excitation
c. Wave speed increases with the increasing d. energy will be transmitted by way of
frequency Compton scattering
d. None of the above 10 When an ultrasound beam is attenuated while
5 Which of the following characteristics of passing through tissue
diagnostic ultrasound applies also to a. a 3 dB loss is equivalent to a 50%
X-radiation? reduction in intensity
a. It is a wave phenomenon b. a 6 dB loss is equivalent to a 100%
b. Its wave speed and frequency are reduction in intensity
inversely proportional c. the normal rate is 10 dB/cm/MHz
c. Matter must be present for transmission d. 90% reduction of the original intensity is
d. Molecular compression and rarefaction equivalent to a 90 dB loss
occur 11 When a transmitted ultrasound beam changes
6 When two or more (plane) ultrasound waves direction across an interface, this is called
exist in the same medium at the same time a. reflection
a. they will interfere constructively if b. defraction
traveling with the same direction and c. refraction
phase d. scattering

127
15 Ultrasound physics and technology

12 Ultrasound and X-rays differ in which of the c. will not travel through a vacuum
following ways? d. is produced and detected by a
a. One is transverse, the other longitudinal transducer
b. One requires matter, the other does not
20 Ultrasound has the following properties. It
c. One has constant wave speed, the other
a. can be deflected by a magnetic field
variable wave speed (in soft tissue)
b. is attenuated in tissue
d. All of the above
c. has a sinusoidal wave form
13 Diagnostic ultrasound intensity is often d. can travel through water
measured in
21 An ultrasound beam is attenuated
a. W/cm2
a. by reflection at a tissue interface
b. grays
b. and causes ionization of atoms
c. rad
c. by scattering
d. decibels
d. by absorption in tissues
14 Intensity is equal to
22 Greater than 50% energy reflection will take
a. power/area
place at a
b. area/power
a. soft-tissue–bone interface
c. amplitude/distance
b. water–soft-tissue interface
d. frequency/wavelength
c. soft-tissue–gas interface
15 Diagnostic ultrasound intensity d. muscle–fat interface
a. increases with increasing frequency
23 The magnitude of the reflected signal
b. is a measure of particle displacement in the
a. decreases as the angle of incidence
conduction medium
approaches 90 degrees
c. is measured in mW/cm2
b. depends on the change of acoustic
d. is the same as ultrasound power
impedance at an interface
16 As ultrasound is transmitted through tissue, its c. is independent of the acoustic
intensity decreases because of impedance
a. excitation d. depends on the frequency of the beam
b. absorption
24 Interference phenomena
c. scattering
a. may occur when two waves interact
d. divergence
b. are more common with continuous
17 Acoustic reflectivity wave ultrasound
a. is determined by acoustic impedance at an c. always produce a wave form of reduced
interface amplitude
b. equals 100 if Z1 ¼ Z2 d. may be of value to ultrasound
c. is higher for an air–soft-tissue
25 Acoustic impedance depends on
interface than a bone–soft-tissue
a. the intensity of the ultrasound
interface
beam
d. increases with increasing frequency
b. the elasticity of the tissue
18 An ultrasound wave may be described as c. tissue density
a. a longitudinal pressure wave d. tissue temperature
b. a transverse wave
26 In which of the following materials is the
c. being formed by particle oscillations
speed of ultrasound greatest?
d. changes in electrical properties of tissues
a. Air
19 Ultrasound used for diagnosis b. Bone
a. has a frequency in the region 2 to 10 kHz c. Water
b. has a velocity in air of 1500 ms-1 d. Soft tissue

128
 Multiple choice answers

27 What is the wavelength of a 5 MHz ultrasound 34 The propagation speed of sound through soft
pulse in soft tissue? tissue is
a. 0.3 mm a. 1450 ms-1
b. 0.5 mm b. 1650 ms-1
c. 3 mm c. 1540 ms-1
d. 5 mm d. 1230 cms-1
28 As frequency increases 35 Given the various physical characteristics of
a. wavelength increases ultrasound, then it is true that
b. imaging depth decreases a. its speed is the same in all materials
c. propagation speed decreases b. its speed does not depend on its frequency
d. a and b c. its speed depends on the density of the
supporting medium
29 The frequency of a sound wave is
d. its speed increases with frequency
determined by
a. the media through which it travels 36 Lateral resolution can be improved by
b. its propagation a. damping
c. its source b. pulsing
d. reflection c. focusing
d. reflecting
30 As frequency increases, the attenuation
coefficient 37 Axial resolution can be improved by
a. decreases a. damping
b. increases b. pulsing
c. stays the same c. focusing
d. attenuation coefficient not affected by d. increasing operating frequency
frequency
38 The resolution of an ultrasound beam may be
31 Which of the following sound frequencies determined by
would include diagnostic ultrasound? a. imaging a series of wires at varying depth
a. 10 Hz from the transducer face
b. 10 kHz b. imaging a series of wires all the same
c. 100 kHz depth from the transducer face
d. 10 MHz c. compound scanning around a Perspex
block containing a single central wire
32 Velocity of ultrasound
d. linear scanning of a single wire in a water bath
a. depends on the transmitted frequency
b. varies for different materials 39 The lateral resolution of the diagnostic
c. is temperature dependent ultrasound system is
d. is equal for muscle and bone a. also called the azimuthal resolution
b. determined by the slice thickness
33 The velocity of an ultrasound beam may be
c. better with higher frequency
determined by measuring the
d. better than axial resolution
a. time taken for a pulse to be returned
through a Perspex block of a known 40 The axial resolution of a transducer is
thickness primarily determined by
b. time taken for a pulse to be returned a. spatial pulse length
through a known depth of water b. the transducer diameter
c. reflection of the beam by a wire mesh c. the acoustic impedance of tissue
placed in water d. density
d. distance between peaks of the wave form

129
15 Ultrasound physics and technology

41 The lateral resolution of a transducer is c. piezoelectric effect

primarily determined by d. transducer effect
a. spatial pulse length
7 A piezoelectric crystal may be made of
b. the beam width
a. aluminum
c. the acoustic impedance of tissue
b. calcium tungstate
d. applied voltage
c. quartz
d. lithium fluoride
The Transducer 8 Best image resolution is obtained
1 The fundamental operating principle of a. at the transducer surface
medical ultrasound transducers is b. in the near field
a. Snell’s law c. in the far field
b. ALARA principle d. in the focal zone
c. piezoelectric effect 9 Crystals for ultrasound transducers are
d. impedance effect composed of
2 Which one of the following quantities varies a. sodium iodide
the most with distance from the transducer b. quartz
face? c. barium titanate
a. Axial resolution d. lead zirconate titanate
b. Lateral resolution 10 The backing material in the transducer is
c. Frequency a. rubber
d. Wavelength b. lead rubber
3 What determines the transducer frequency c. resin loaded with metal
selection for diagnostic ultrasound? d. plastic
a. Intensity and resolution 11 The acoustic insulator in a transducer
b. Intensity and propagation speed a. is a safety device
c. Scattering and impedance b. reduces ‘ringing’
d. Resolution and penetration c. is the main factor in shortening the pulse
4 Which of the following improves sound length
transmission from the transducer element into d. absorbs ultrasound
the tissue? 12 Phased array transducers
a. Matching layer a. have elements which emit ultrasound
b. Doppler effect independently
c. Damping material b. may be used to alter the beam direction
d. Coupling medium c. are used only on real-time scanners
5 The active elements of the diagnostic d. have a variable frequency
ultrasound transducer 13 A linear array transducer
a. may be crystalline material a. has multiple elements of the same
b. operate on the basis of the photoelectric effect piezoelectrical material
c. convert electrical energy into mechanical b. can be used to produce real-time images
energy c. always has a frequency of 3.5 MHz
d. convert mechanical energy into electrical d. does not employ a coupling medium
energy
14 Bandwidth
6 The principle on which the ultrasound a. indicates the range of frequencies present
transducer operates is the b. is related to the pulse length
a. photoelectric effect c. is fixed for a particular transducer
b. crystalline effect d. is mainly determined by patient size
130
 Multiple choice answers

15 A coupling medium 6 Scan converters

a. is always used between the transducer a. are used only with conventional B scanners
and the patient’s skin b. may be either analog or digital
b. is only used to help the transducer c. employ an electron gun and deflection
slide over the surface, thus reducing system
friction d. increase the gray scale of the image
c. eliminates air, thereby allowing maximum
7 The dynamic range of an ultrasound system
transmission of the beam
a. is expressed in decibels
d. must be a water-soluble gel
b. is a measure of resolution
c. expresses the range of the signal
amplitudes that can be recorded
Instrumentation d. depends mainly on the frequency
1 The dynamic range of an ultrasound system is employed
defined as 8 Artifacts in B scanning can be caused by
a. the speed with which ultrasound a. reverberation
examinations can be performed b. refraction
b. the range over which the transducer can be c. misregistration
manipulated d. room temperature changes
c. the ratio of the maximum to the minimum
intensity that can be displayed
d. the range of pulser voltages applied to the
Doppler
transducer
1 The Doppler effect
2 The operation of the signal processor that
a. measures the change in frequency of
reduces noise is
ultrasound
a. filtering
b. results from the movement of interfaces
b. TGC
c. may be used to determine blood vessel
c. scan conversion
patency
d. compression
d. is always detected in audible sound
3 Increasing the gain generally produces the
2 The Doppler shift frequency
same effect as
a. depends on acoustic impedance
a. decreasing the attenuation
b. is independent of the direction of move-
b. increasing the compression
ment of the interface
c. decreasing output power
c. detected, will be greater at 5 MHz than at
d. increasing the output power
2 MHz
4 The TGC control compensates for d. is normally detected by a single
a. focusing transducer
b. machine instability
3 The Doppler shift frequency is
c. transducer aging
a. inversely proportional to the velocity of
d. attenuation
movement of an interface
5 Ultrasound is used in diagnosis to b. directly proportional to the pulse repetition
a. produce dynamic images of physiological frequency
functions c. inversely proportional to the velocity of
b. demonstrate soft-tissue structures ultrasound in a medium
c. monitor heart valve movement d. dependent on the transmitted
d. produce three-dimensional images frequency

131
15 Ultrasound physics and technology

Safety c. when deeper organs are being

visualized
1 Ultrasound beams may produce
d. if the dynamic range is increased
a. cooling of the tissues
b. cavitations 3 In the exposure of the tissues to ultrasound
c. cavitations independent of the frequency used a. the units of intensity are mW/cm2
d. streaming b. the unit of ultrasound dose is the rad
c. if the beam is said to have a 30 dB gain, that
2 Doses to the patient undergoing ultrasound
means it is 30% more intense than the
examinations are increased
reference beam
a. if the pulse repetition frequency is
d. if the reflected ultrasound beam is 40 dB,
increased
it is only 0.1% of the transmitted beam
b. if the intensity is reduced and the gain is
increased

132
 Index
......................................................................................................................................

lA....................... frequency and wavelength, 16

safety, 93, 94, 98
Absorption, 7, 46 sector width, 69–70
Absorption coefficient, 46, 95 spectral Doppler, 84–85
Acoustic enhancement, 54–55 Background noise, 67
Acoustic impedance (Z), 2, 19–22 Bandwidth, 31, 32
definition, 7 Baseline acceptance tests, 102
formula, 19, 20 Beam, 11, 23–26
matching layers, 9, 30–31 Doppler, angle, 76–77, 81–82, 85
mismatch, 21–22, 46 focusing see Focusing, beam
piezoelectric crystal, 16 generation, 33–34
reflection and, 20–21 intensity, 24
ultrasound imaging and, 21–22 shape, 23–24
various substances, 20 side lobes, 24–25
Acoustic lens, 30 slice thickness, 25
Acoustic power, 7 steering, 36
Acoustic shadowing, 53–54 Beam former, 8, 26, 35
Acoustic waves, 7 control, 64
Acoustic window, 7 digital, 111–112
ALARA principle, 7, 97 Beam width, 25
Aliasing, 88 factors affecting, 42
color flow imaging, 82–83 lateral resolution and, 41–42
spectral Doppler, 86–87 Beam width artifact, 56, 57
American Institute of Ultrasound in Medicine (AIUM), Biological effects of ultrasound, 94–97
94, 95, 97 Blood flow
Amplitude, 7, 92 color flow imaging, 79–80
attenuation, 45 continuous wave Doppler, 78–79
detection, 65 Doppler effect, 75–76
of oscillation, 15 Blood flow velocity (V), 76
Analog to digital conversion, 42 color flow imaging, 80–81
Anechoic, 7 Doppler shifted signals, 77–78
Artifacts, 7, 51–62 Brightness control, 65
Doppler, 88–89 British Medical Ultrasound Society (BMUS), 97, 98
Attenuation, 8, 45–49
machine controls, 67
Attenuation coefficients, 45
lC.......................
Australasian Society for Ultrasound in Medicine, 97
Axial resolution, 8, 29, 40–41 Calipers, electronic, 105, 108
factors affecting, 41 Cavitation, 8, 96, 97
spatial pulse length and, 40 stable, 96
testing, 106–107 unstable, 97

.......................
Cineloop
control, 66, 69
lB video clips, 66
Color flow imaging, 79–84, 88
B-mode ultrasound aliasing, 82–83
color flow imaging, 80, 81 beam angle, 81–82
133
 Index

Color flow imaging (Continued) Doppler tissue imaging (DTI), 118

color box, 80–81 Doppler ultrasound, 73–89
color scale, 81 artifacts, 87–89
depth, 83–84 history, 3
PRF, 83 imaging techniques see Doppler imaging
safety, 94 non-imaging techniques, 78–79
spectral Doppler with, 85 safety, 93–94
Compound imaging, 112, 113 types of instrumentation, 78–87
Compression, 2 Double image artifact, 59, 60
signal, 65 Duplex imaging, 80
Contact coupling, 8 Dwell time, 94
Continuous wave (CW) Doppler, 16, 78–79 Dynamic range, 8, 70
Continuous wave ultrasound beam, 23–24 incorrect use, 60, 61
Contrast testing, 108
control, 65
excessive, 60, 61
Contrast agents, 96, 116
lE.......................
see also Microbubbles
Contrast resolution, 42 Echo, 2, 8
optimizing, 43 Echogenic, 9
Controls, machine, 66–70, 98 Edge enhancement, 65
Coronal plane, 8 Edge shadowing, 55–56
Coupling, contact, 8 Elastography, 117–118
Curie, Jacques and Pierre, 29 Electrical and mechanical safety, 108–109
Curie temperature, 13–14 Electrical shock, 9
Curvilinear array transducers, 36, 37 Electronic array transducers, 31–32, 36–37

.......................
image formation, 33, 34
Energy conversion efficiency, 16
lD Enhancement, acoustic, 54–55
Epidemiological studies, ultrasound safety, 98–99
Equipment, 4
Decibels (dB), 70 assumptions made, 51–52
Definitions, terminology, 7–11 baseline acceptance tests, 102
Depth, 8, 68–69 electrical and mechanical safety, 109
color flow imaging, 84 generation of artifacts, 59–61
penetration see Penetration depth for image performance testing, 103, 104, 105
Depth gain compensation (DGC) see Time gain performance testing, 102–109
compensation user tests, 103
Diffraction, 48–49 see also Ultrasound machine
Diffuse reflection, 47, 48 European Federation of Societies of Ultrasound in
Diffuse reflectors, 8 Medicine and Biology, 97
Digital beam forming, 111–112 Excess pressure (P), 19, 20
Display, image, 66 Exposure time, 98
Divergence, 48–49 Extended field of view (FOV) images, 112, 113

.......................
Doppler angle (y), 76–77, 81–82, 85
Doppler effect (shift), 8, 74–75
applied to diagnostic ultrasound, 75–76 lF
Doppler equation, 76–78
Doppler imaging, 78, 79–87 Far field (Fraunhofer zone), 11, 23, 24
artifacts, 88–89 divergence, 49
color flow imaging, 79–84 Fast Fourier transform (FFT), 86
modes compared, 88 Fetal heart monitoring, 78
power Doppler, 84, 88 Field of view (FOV), 41
spectral or pulse wave Doppler, 84–88 extended images, 112, 113
Doppler mirror image, 88 Filtering, 65
Doppler principle, 74–75 Flash artifact, 89
Doppler shifted signal (Fd), 75, 76 Focal zone, 11, 24, 31
blood flow velocity and, 76 beam width artifact and, 56
typical values, 77–78 multiple, 35, 69

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 Index

Focus, 9, 69 resolution see Spatial resolution

Focusing, beam, 25–26 storage, 66
effect on lateral resolution, 30, 31 Image processor, 65
electronic transducers, 34–35 Impedance see Acoustic impedance
lateral resolution and, 42 Impedance matching layers, 9, 30–31
Food and Drug Administration (FDA), 94, 95, 97 Incidence, angle of, 47
Four-dimensional (4-D) imaging, 114 Institute of Physics and Engineering in Medicine
Frame, lines per, 42–43 (IPEM), 102
Frame rate, 42–43 Instrumentation, 63–71
incorrect use, 61 Doppler, 78–88
sector width and, 69–70 see also Equipment; Ultrasound machine
Frames per second (fps), 69 Intensity (I), 9, 92–93
Fraunhofer zone see Far field attenuation, 45
Freeze control, 66, 69 beam, 24
Frequency, 9 machine controls influencing, 98
attenuation and, 45 pulse average (IPA), 93
axial resolution and, 41 regulatory limits, 94
Doppler shift, 75–76 spatial average (ISA), 93
factors affecting, 16 spatial peak (ISP), 93
heat generation and, 95 temporal average (ITA), 93
high frequency imaging, 112 temporal peak (ITP), 93
lateral resolution and, 42 Intensity reflection coefficient, 21
Fresnel zone, 11, 23, 24 Intensity reflection equation, 21

....................... Interactions, ultrasound, 45–49

Isoechoic, 9

.......................
lG
Gain, 9 lL
incorrect use, 59–60, 61
overall control, 9, 67 Lateral resolution, 9, 30, 41–42
Grating lobes, 25 testing, 106–107
Gray-scale imaging, 4 Lead zirconate titanate (PZT), 9, 29
testing, 108–109 Lens, acoustic, 30
see also Dynamic range Linear array transducers, 36, 37
Guidelines color flow imaging, 81–82
quality assurance testing, 102 spectral Doppler, 85
safety, 97–98, 99 Lines per frame, 42–43

lH....................... Lithotripsy, 94–95

Log compression, 69–70
see also Dynamic range
Longitudinal plane, 10

.......................
Hard copy image storage, 66
Harmonic imaging, 115–116
Heat, 9, 46, 95–96 lM
High frequency imaging, 112
History of ultrasound, 2–3 Machine, ultrasound see Ultrasound machine
Hyperechoic, 9 Measurements, 71
Hypoechoic, 9 testing accuracy, 105

.......................
Mechanical effects, 4, 97
Mechanical index (MI), 8, 94, 97
lI guidelines, 98
Megapascals (MPa), 92
Image, 4 MI see Mechanical index
characteristics, 9 Microbubbles, 116
controls, 67–70 pulse inversion imaging, 117
display, 66 safety, 96, 97
formation, 32–33, 34 targeted, 116
measurements, 71 Mirror image artifact, 59, 60
memory, 66, 69 Doppler, 88
processing, 65 Misregistration, 48

135
 Index

lN....................... Pulse repetition frequency (PRF), 10

color flow imaging, 83
depth and, 67
National Electrical Manufacturers Association (NEMA), spectral Doppler, 87
94, 95 temporal resolution and, 42–43
Near field (Fresnel zone), 11, 23, 24 Pulse transmitter (pulser), 10, 64
New technology, 111–119 Pulse wave Doppler see Spectral Doppler
Noise, background, 67 Pulsed sound wave, 16, 23–24

....................... .......................
Nyquist limit, 83

lO lQ

Object separation method, 106–107 Quality assurance (QA), 101–110

Oscillation, amplitude of, 15 electrical and mechanical safety, 109
Output display standards (ODS), 94, 95 equipment performance testing, 102–109
Output power, 67, 98 limitations of testing, 109–110
Overall gain control, 9, 67 Quartz, 29

lP....................... ....................... lR
Particle velocity (U0), 19, 20 Rarefaction, 2
Penetration depth, 67 Real-time scanning, 3
testing, 107–108 Receiver, 64
Performance testing, 102–109 Reflection, 10, 46–47
levels, 102–103 acoustic impedance and, 20–21
limitations, 109–110 diffuse, 47, 48
parameters measured, 104–109 specular, 46
phantoms, 103, 104, 105, 109 Refraction, 10, 48
Peripheral blood flow assessment, 79 Resolution, 10, 39–43
Phantoms, test, 103, 104, 105, 109 axial see Axial resolution
Phased array transducers, 37 contrast, 42
Picture archiving and communications system (PACS), lateral see Lateral resolution
66 optimizing, 43
Piezoelectric crystals, 4, 13–16, 29 spatial see Spatial resolution
acoustic impedance, 16 temporal, 10, 42–43
diameter (aperture), 42 Resonance, 16
energy conversion efficiency, 16 Resonant frequency, 16, 29
pulsed sound wave production, 16 Reverberation, 52–53
reception of sound, 15–16 Ringdown, 52, 53, 54
resonant frequency, 16, 29 Risk/benefit assessment, 94

.......................
thickness, 29
transmission of sound, 14–15
wavelength/frequency output, 16 lS
Piezoelectric effect, 10, 13–17, 29
Piezoelectric materials, 13–16 Safety of ultrasound, 3–4, 91–99
Portable ultrasound machines, 118 ALARA principle, 97
Power (P), 10, 92, 98 biological effects, 94–97
output, 66, 98 epidemiological evidence, 98–99
Power Doppler, 84, 88 guidelines, 97, 98
safety, 94 important parameters, 92–93
Presets, 10, 66 machine controls influencing, 98
PRF see Pulse repetition frequency operating modes, 93–94
Probes see Transducers regulatory control, 94, 95
Processor, 65 Sagittal plane, 10
Propagation, 46 Scattering, 10, 47–48
Propagation speed, 10 Sector field of view, 32, 33, 37
Pulse-echo principle, 2, 10 Sector width (angle), 69–70
Pulse inversion imaging, 116–117 Sensitivity, testing, 107–108

136
 Index

Shadowing Tissue characterization, 118

acoustic, 53–54 Tissue equivalent (TE) phantoms, 103, 104, 105
edge, 55–56 Tissue motion, 118
Side lobe artifact, 58 Transaxial plane, 11
Side lobes, 24–25 Transducers, 4, 11, 27–37, 63–64
Signal compression, 65 backing (damping) material, 11, 29, 30, 41
Signal processor, 65 bandwidth, 31, 32
Single wire method, 107 broad bandwidth, 115
Slice thickness, 25 components and construction, 28–31
Slice thickness artifact, 56–57, 58 early mechanical, 32–33
Snell’s law, 48, 49 electrical connections, 28–29
Soft copy image storage, 66 electronic beam focusing and steering, 33–36
Sonar, 2 electronic multi-array see Electronic array
Sound, 1–2, 11 transducers
waves, 1–2 housing, 11, 28
Spatial pulse length (SPL), 29 image formation, 32–33, 34
axial resolution and, 40 operating frequency, 29
bandwidth and, 31, 32 orientation, 11
factors affecting, 41 piezoelectric element, 29
Spatial resolution, 11, 25, 39–42 stationary, safety, 98
optimizing, 43 Transverse plane, 11
testing, 105–107 Triplex imaging, 85

.......................
Spectral analysis, 86
Spectral Doppler (pulse wave or PW Doppler),
84, 88 lU
aliasing, 87
frequency and wavelength, 16 Ultrasound, 2
generation of signals, 86 Ultrasound beam see Beam
safety, 93–94 Ultrasound machine, 63–70
signal processing and display, 86 components, 63–66
Specular reflection, 46 controls influencing safety, 98
Specular reflectors, 11 function of controls, 67–70, 71
Storage, image, 66 measurements, 70

lT....................... portable, 118

system configuration/presets, 66
see also Equipment
Temporal resolution, 11, 42–43
Terminology, definitions, 7–11
Texture, 11
lV.......................
TGC see Time gain compensation Velocity, blood flow see Blood flow velocity

.......................
Thermal effects, 4, 46, 95–96
Thermal index (TI), 9, 94, 95–96
guidelines, 99 lW
Three-dimensional (3-D) imaging, 112–114
electronic, 114, 115 Wavelength, 11
free hand, 113–114 factors affecting, 16
mechanical, 114 spatial resolution and, 39
TIB, 96 World Federation for Ultrasound in Medicine and
TIC, 96 Biology (WFUMB), 95, 97

.......................
Time gain compensation (TGC), 11, 45–46
acoustic enhancement and, 55
control, 67–68 lZ
incorrect use, 59–60, 61
processes involved, 68 Z see Acoustic impedance
TIS, 96 Zoom, 70

137