BASIC PHYSICAL PRINCIPLES OF ULTRASOUND

BASIC PHYSICAL PRINCIPLES OF ULTRASOUND

INTRODUCTION

C
ompetent performance of an ultrasound examination of any type is reliant on
an understanding of the basic physical principles that govern the production
of ultrasound waves and their interaction with biological tissues of differing
densities and consistencies. It is also necessary to understand the basic concepts of
how the ultrasound systems work and the concepts underlying their manipulation of
echoes.

Given a working knowledge of these various concepts and an understanding of how

the theoretical principles can be put to use in a practical arena, physics of ultrasound
becomes the bedrock upon which to build all the other knowledge necessary in
becoming a competent sonographic diagnostician.

Lectures and notes provided during this course are the barest essentials of the
learning you will require and our emphasis will be on the practical application of the
principles involved. Further theoretical knowledge can be gained by wider reading
and study. Recommended texts are as follows:

1. Applied Physics and Technology of Diagnostic Ultrasound; Author – Roger

Gent
2. Diagnostic Ultrasound, Principles and Instruments (Fifth Edition); Author –
Frederick Kremkau

WHAT IS ULTRASOUND?
Simply stated, ultrasound is sound whose frequency is above the range of human
hearing. Diagnostic ultrasound is used to evaluate a patient’s internal organs.
Sound waves are transmitted into the body; then, because the various internal
structures reflect and scatter sound differently, returning echoes can be collected
and used to form an image of a structure.

Sound waves consist of mechanical variations containing condensations or

compressions (zones of high pressure) and rarefactions (zones of low pressure) that
are transmitted through a medium.

B e a m D i r e c ti o n

Unlike X-Rays, sound is not electromagnetic. Matter must be present for sound to
travel, which explains why sound cannot propagate through a vacuum. Propagation
of sound is the transfer of energy - NOT MATTER – from one place to another within
a medium, some energy is also imparted to the medium.

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Sound is categorised according to its frequency (number of mechanical variations

occurring per unit time):

Human Audible range 20 – 20000Hz

Diagnostic Ultrasound 1 – 20MHz
(3-12MHz being the most common range)

WAVE TERMINOLOGY
The characteristics of a sound wave can be described by the following parameters:

· Period (T) – the time taken for a particle in the medium through which the
wave is traveling to make one complete oscillation about its rest position.
(One oscillation is also referred to as a cycle)

· Frequency (f) – the number of cycles per second performed by the particles of
the medium in response to a wave passing through it. Expressed in Hertz,
where I Hz = 1 cycle passing a given point each second, therefore 3MHz = 3
million cycles per second

· Wavelength (l) – the distance between two consecutive, identical positions in

the pressure wave (e.g. between 2 compressions or between 2 rarefactions).
It is determined by the frequency of the wave and the speed of propagation in
the medium through which it is traveling. In diagnostic ultrasound, commonly
used frequencies and their respective wavelengths in soft tissue are as
follows:
Frequency - 3MHz / Wavelength – 0.51mm
Frequency – 5MHz / Wavelength – 0.31mm

· Velocity (c) – speed of sound with direction specified. When a sound wave
travels through any medium it is certain parameters of that medium, which
determine the speed of sound propagation. These determining factors are
density and compressibility. Therefore, speed of sound is a characteristic of
each material through which sound travels; e.g.

Material Speed of Sound

Air 330 metres/second
Metal 5000 m/sec
Pure Water 1430 m/sec

Speed of sound in various organs of the body also differs; e.g.

Soft Tissue Type Speed of Sound

Fat 1450m/sec
Liver 1550m/sec
Blood 1570m/sec
Muscle 1585m/sec
Bone 4080m/sec

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In practical terms, ultrasound machines need to operate on a single value for

speed of sound in soft tissue; therefore an average speed for soft tissue is
taken to be 1540m/sec.

Ü This can be extremely important when learning about artifacts later, since
differences between the actual speeds of sound and those inferred by the ultrasound
machine can cause misregistration of echoes on the image.

· Amplitude (A) – maximum variation of an acoustic variable, thus amplitude is

a measure of the degree of change within a medium when a sound wave
passes through it and relates to the severity of the disturbance. In this way,
the amount of energy in a sound wave can be determined. Amplitude is
expressed in units that are appropriate for the acoustic variable considered.

Amplitude
Pressure

· Power (W) – the rate at which work is done or the rate of flow of energy
through a given area. In diagnostic ultrasound energy is contained within the
beam, so the power is the rate of flow of energy through the cross-sectional
area of the beam. Power is expressed in Watts.

· Intensity (I) – power per unit area. Intensity is expressed in milliwatts per
square centimeter (mWatts/cm2). Intensity is an important parameter in
describing an ultrasound beam and in the understanding of bioeffects and
safety. The example of sunlight shining on wood shavings is often used to
illustrate this phenomenon – Sunlight does not usually burn wood shavings
but when the sunlight is concentrated into a small area (increased in intensity)
by a magnifying glass, the wood shavings can be burnt. So, power remains
the same, intensity is increased and an effect is produced (increased heat).

The scout can burn the

wood shavings with the
aid of a magnifying
glass to focus the sun’s
rays, therefore
increasing the intensity.

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ÜIMPORTANT SUMMARY DIAGRAMS TO REMEMBER

CYCLE – ONE COMPLETE OSCILLATION OF THE WAVE

FREQUENCY – NUMBER OF CYCLES PER SECOND OF TIME

1 SECOND

WAVELENGTH – LENGTH OF ONE COMPLETE CYCLE

Frequency and wavelength have an inverse relationship shown in the formula c = fl,
where c is the speed of sound in tissue, f is the frequency and l is the wavelength.
Therefore, the higher the frequency, the shorter the wavelength. This relationship is
fundamental to practical scanning since it has a considerable effect on the
achievable penetration depth and resolution of the ultrasound beam.

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T HE PIEZO-ELECTRIC EFFECT
Artificially grown crystals are commonly used for modern transducers and are treated
with high temperatures and strong electric fields to produce the piezo-electric
properties necessary to generate sound waves

The principle of piezo-electricity is central to the production of ultrasound beams and

states that some materials produce a voltage when deformed by an applied pressure
and produce a pressure when deformed by an applied voltage.
Thus, when a voltage is applied to the faces of a crystal, it expands or contracts
depending upon the polarity of the voltage applied. The crystal then resonates,
converting electricity to ultrasound. The frequency of sound produced is dependant
on the thickness of the crystal. Conversely, the when the crystal receives an echo,
the sound deforms the crystal and a voltage is produced on its faces – this voltage is
then analysed by the system.

Piezo-electric effect: Reversing polarity of voltage

Crystal undergoes expansion & contraction

If expansion & contraction occurs more than 20000 times per second, then
ultrasound is being produced, which will continue until the applied voltage is
discontinued (Continuous wave). If voltage is applied for an extremely short time,
then the crystal resonates (rings) at its own frequency and the ringing gradually
decays – a pulse is produced. The larger the voltage applied the greater the
amplitude of the emitted sound (louder ringing).

Very short pulses are required for diagnostic ultrasound images to be produced, so
the ringing of the crystal is stopped short by a damping material being applied to
absorb vibrations (a hand placed on a bell will stop the ringing).

PULSE-ECHO IMAGING
Images produced by diagnostic ultrasound systems are formed by sending out a
short pulse of sound along a narrow beam path and waiting for return echoes to be
collected from structures encountered along that path. The instrument generating
and receiving those pulses of sound is the transducer, which is a critical component
of the system due to its profound effect on image quality.

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B ASIC T RANSDUCERS

Simply stated the basic transducer consists of three parts:

1. The Case
2. The Crystal
3. The Damping material
These are connected to the ultrasound system by electrical wiring.

case

cable crystal

damping material

Multi-element Transducers

Most real time transducers use many small crystal elements for the formation of
each pulse.

Multiple crystal elements

These form a line of elements and the transducers are known as linear array
transducers. The wave fronts from each element combine to form a single wave
front; this is known as Huygen’s Principle. Each individual element is acoustically
and electrically isolated, allowing flexibility in beam formation.

B EAM PROFILE
The shape of the ultrasound beam is important to the quality of the image it
produces. The shape of the beam from a simple transducer is shown below.

The beam profile is made up of three parts:

1. Near Field (Fresnel Zone)
2. Far Field (Frauhofer Zone)
3. Transition Point – point at which near field ends and divergence begins

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(The length of the near field is often termed the transition distance)

Near Field

Transition Point
Far Field
Ü All sound beams are three-dimensional

The near field is the part of the beam useful for imaging purposes; however this can
be quite large in area, depending on the diameter of the crystal. Imaging requires a
very narrow beam to produce high-resolution diagnosis. Focussing is used to
achieve these narrow beams, there being various focussing methods in use
throughout the manufacturing industry and new methods are being devised with
each passing year.

Simple methods are to curve the crystal, add a curved lens in front of the crystal or
focus by electronic means (the latter being the most common in today’s
transducers).

DIFFRACTION PATTERN

A beam profile of a simple transducer obtained by plotting the maximum pressure

amplitude appears as in the diagram below and shows that the energy is not
confined to a single lobe, but radiates off at various angles to the transducer face as
“off-axis” energy. These off-axis areas are called side-lobes.

Side lobes

Ü SIDE LOBES ARE

Primary Beam THREE-DIMENSIONAL &
SURROUND THE PRIMARY BEAM

Side lobes

Array transducers also generate grating lobes which are defined as additional,
weaker beams of sound energy travelling out in different directions from the primary
beam as a result of the multi-element structure of transducer arrays.
Both side lobes and grating lobes are minimised as far as possible by the
manufacturer during the design process but nevertheless still produce artifactual
echoes within images. (See artifact section)

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RESOLUTION
Resolution is defined, as the ability to distinguish echoes in terms of space, time or
strength and good resolution is thus critical to the production of high quality images.

1. CONTRAST RESOLUTION refers to the ability of an ultrasound system to

demonstrate differentiation between tissues having different characteristics e.g.
liver/spleen.

2. TEMPORAL RESOLUTION is the ability of an ultrasound system to accurately show

changes in the underlying anatomy over time, this is particularly important in
echocardiography.

3. SPATIAL RESOLUTION is the ability of the ultrasound system to detect and display
structures that are close together. Since an ultrasound image displays depth into
the patient and width across a section of anatomy it is therefore reasonable to
consider two types of spatial resolution – Axial & Lateral.

AXIAL RESOLUTION
The ability to display small targets along the path of the beam as separate
entities.
Good Resolution Poor Resolution

Axial resolution is dependent upon various factors, the most important of which
being the length of the pulse used to form the beam. This is known as the spatial
pulse length (SPL). The shorter the pulse length, the better the axial resolution.
In fact the axial resolution limit is defined as being one half of the SPL.

Ü AXIAL RESOLUTION LIMIT = ½ SPATIAL PULSE LENGTH

The SPL is determined by the number of cycles in one pulse and the length of
each cycle (i.e. wavelength - this cannot be changed by the operator). However,
wavelength, as we have already said, is inversely proportional to the frequency,
so higher frequencies generate shorter wavelengths and therefore shorter pulse
lengths. So we can say that higher frequency transducers will exhibit better axial
resolution.

One note of caution should be that all transducers of a particular frequency will
not necessarily have the same axial resolution, since other factors such as
damping levels can have an effect on the SPL.

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Other factors affecting the axial resolution, which the operator can control, are:
¨ Transmit power – the greater the amplitude of the voltage striking the crystal, the
longer the ringing time and longer the SPL, leading to a slight decrease in axial
resolution
¨ Received gain settings effect the length of the voltage signals generated by the
returning echoes, the higher the gain – the poorer the axial resolution
¨ Field of view settings effect the display of pixels per unit area of the patient –
smaller FOV setting makes best use of the available scan converter memory

LATERAL RESOLUTION
The ability to distinguish between two separate targets perpendicular to the
beam path. (Same distance from the transducer)

Good Resolution Poor Resolution

Lateral resolution is dependent upon the width of the ultrasound beam, that is – the
wider the beam, the poorer the lateral resolution. Ultrasound machines assume that
all received echoes arise from the central axis of the beam, so if two targets are
within the beam at the same point in time, the echoes are assumed to have come
from the same target and only one structure is registered on the image. If the beam
is narrower than the distance between the two targets, only one target is within the
beam at one time and as the transducer is swept across the body, both targets will
be interrogated separately and both will be registered on the image. (See diagram)
DIRECTION OF SCAN IMAGE

TARGETS SAME
WIDTH APART

Where the beam width is at its narrowest, the targets are separated by a distance
greater than the beam width and thus are resolved on the image.

As we can see, the lateral resolution is best where the beam is the narrowest and
thus in the area of tightest focus in most transducers.

Ü CORRECT POSITIONING OF THE FOCAL ZONES IS CRITICAL TO GAINING THE

BEST LATERAL RESOLUTION FOR A GIVEN TRANSDUCER

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INTERACTION OF SOUND WITH TISSUE

ATTENUATION

A
s the sound beam traverses tissues within the body, various factors cause it to
lose energy and therefore undergo a reduction in amplitude and intensity.
This loss of energy is called attenuation. The amount of attenuation is
determined by the tissue involved, the distance travelled and the frequency of the
beam. The dependence of attenuation on frequency is of major importance in
practical terms, since it is this dependence, which limits the penetration of an
ultrasound beam of a given frequency and makes TGC controls a necessity in
diagnostic ultrasound systems.

There are four main processes, which contribute to the attenuation of the sound
beam, which are:
O Reflection
O Refraction
O Absorption
O Scattering

All of the above factors affect the echoes returning to the transducer as well as the
transmitted beam.
ÜThe amount of attenuation depends on the total path length. (The
time taken for the sound to reach the interface and the echoes to
return)
ÜThe approximate rate of attenuation in soft tissue is 1dB/MHz/cm
REFLECTION
This occurs at interfaces between soft tissues of differing acoustic impedance, an
alternative name for which is an acoustic impedance mismatch. Reflection occurs
where the interface is large relative to the wavelength of the transmitted sound.

At tissue interfaces some of the sound is reflected and some is transmitted further
into the soft tissue. The percentage of the sound reflected is dependent on the
magnitude of the impedance mismatch and the angle of approach to the interface.

O Soft tissue/air interface - 99.9% reflected

O Soft tissue/bone - 40% reflected
O Liver/Kidney - 2% reflected

Specular Reflections occur at large, smooth interfaces (e.g. Diaphragm, organ

margins), in these cases the angle of incidence equals the angle of reflection.

Clinical Note:
ÜAvoid bone, gas and air interfaces with soft tissue - little sound is
transmitted which produces shadowing of deeper tissues.
ÜTry to use a soft tissue “window” to view deep structures
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REFRACTION
Refraction is the deviation in the path of a beam, occurring when the beam passes
through interfaces between tissues of differing speeds of sound, when the angle of
incidence to an interface is not 90°

q1

Tissue 1
Tissue 2

q2

Refraction at an interface between tissues of differing velocities

Variations in velocity between soft tissue organs are generally fairly small (up to
10%). Deviations of the sound beam of up to 10° may occur, with resultant
misregistration of echoes on the display.
ÜRefractions can produce some recognised artifacts.
ABSORPTION
Transfer of some of the energy of the beam to the material through which the sound
is traveling.
Ü Absorption increases with frequency
Ü Absorption produces a heating effect
ÜClinical note: The increase in absorption with frequency explains why
high frequency transducers cannot be used for examining deep structures
within the body.

Understanding a little cloudy?

Absorption is a fairly complex subject, the physics of

which we have not attempted to describe in detail.

Further reading from recommended physics text may blow

away the clouds!

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SCATTERING
Scattering occurs at interfaces within the sound beam path. The scatter pattern
relies on the size of the interface relative to the wavelength of the sound.

O Interface much larger than wavelength - Reflection (see page 10)

O Interface equal in size to wavelength – scatter in many directions with
amount not being equal in all directions. (sometimes termed non-specular
reflection)
ÜClinical Note:
Provides much of the textural information present in images and is dependent
upon:
a. Frequency
b. Angle of approach
O Interface much smaller than wavelength - Rayleigh scattering, which is
equal in all directions (not angle dependent)

ÜClinical Note:
This type of scattering is caused by red blood cells and provides signals for
Doppler assessment of blood flow.
IMAGE PRODUCTION
The images we use in diagnostic ultrasound are produced with B-Mode or brightness
mode techniques. This can be described as a pattern of dots positioned on the
monitor, as a result of the signals caused by returning echoes being processed by
the system. The brightness of each dot is in proportion to the strength of the echo
received.

As each pulse is emitted, its line of sight is known accurately and therefore the
resulting echoes from sound/tissue interactions along this line are represented on
the monitor in accurate spatial position.

Multiple lines of sight produced at known angles from the transducer then construct
an image of the underlying tissue, composed of multiple thousands of dots. This
image is known as a frame. Multiple frames produced in rapid succession form the
moving or real-time image we see on the ultrasound monitor. Frame rates in modern
systems are typically 10 – 30 frames per second and a flicker free image is achieved
using electronic smoothing techniques.
T RANSDUCERS
Several types of transducer are available, their construction varies depending upon
the type of examination they have been been produced to facilitate. Some of these
are:
O Mechanical sector
O Electronic sector (phased array)
O Annular array
O Linear array
O Curved array

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O Specialised (intracavitary, intraoperative)

The types of transducer we use the vast majority of the time in general ultrasound
practice are Linear and Curved arrays.

LINEAR ARRAY CURVED ARRAY

The transducer is constructed with SIMILAR IN CONSTRUCTION TO THE

multiple small crystal elements LINEAR ARRAY EXCEPTING THAT THE
arranged in a straight line (thus FACE OF THE TRANSDUCER IS CONVEX.
linear) across the face of the probe. SINCE THE BEAM PATHS REMAIN AT
These elements are pulsed
90° TO THE TRANSDUCER FACE, THE
sequentially in groups in order to
produce a wider aperture and RESULTING FIELD OF VIEW IS WIDER
resultant improved beam shape. AT THE BOTTOM OF THE IMAGE
WHILST REMAINING A REASONABLE
The beams generated by these WIDTH IN THE NEAR FIELD OF VIEW
transducers travel at 900 to the
transducer face. Thus the lines of
sight are parallel, the line density is
uniform from top to bottom of the
image and the field of view is
rectangular.

Linear Array Field of View

Field of View Transducers produced by different

manufacturers may have similar
frequency, size and shape, but can
have quite different beam shapes
and focussing due to the particular
construction used by the
manufacturer. They can have
widely varying numbers of elements
and so aperture widths.
Ü Get to know your
transducers and their capabilities

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ARTIFACTS

U ltrasound systems operate on the basis of certain assumptions relating

to the interaction of the sound beam with soft tissue interfaces, such as:

1. A constant speed of sound in the body (assumed 1540m/s)

2. All echoes detected by the transducer originate from the central axis of
the beam
3. The ultrasound beam travels in straight lines
4. The time taken for an echo from a given interfaces to return to the
transducer is directly related to its distance from the transducer
5. The rate of attenuation of the beam is constant with depth and
throughout the field of view

These assumptions are often incorrect, resulting in images that do not

accurately reflect the anatomy of the scan plane. Several effects of these
incorrect assumptions result in artifactual echoes with the display, these effects
can produce:

1. Echoes in the display which do not appear in the correct position

2. Absence of echoes from parts of the image representing tissue which
would normally generate echoes
3. Structures which are anatomically separate being displayed as joined
4. Brightness of echoes which may not correspond to that expected from a
particular organ
5. Single structure being displayed as two separate structures
6. Thin membranes appearing thicker than they really are.

The list below describes, in simplistic form, some of the common artifacts, some
of which offer useful diagnostic information.

Acoustic Shadowing

If the proportion of the beam energy attenuated at a given interface is high, little
sound will be transmitted deeper than the interface, and then echoes will not be
received from tissue deep to the interface. When this occurs, an acoustic
shadow is produced.

Some interfaces causing such effects are:

O Soft tissue/gas (bowel, lung)
O Soft tissue/bone, calcium (ribs, calculi)
O Normal tissue/fibrous tissue (scars, ligaments)

Bright Echo originating

ÜShadows from calcium and bone
from leading edge of are usually echo free (“clean”)
interface

ÜShadows from gas are often

Acoustic Shadow
partially filled with reverberations
(“dirty”)
ÜFocal zone MUST be set at depth
of calculus to clearly show a shadow

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Acoustic Enhancement
Acoustic enhancement is an attenuation phenomenon resulting in an area of
increased brightness (amplitude) in the display, relative to echoes from adjacent
similar tissue.

The basis for this artifact is that fluid filled structures (cysts, gall bladder etc)
attenuate sound to a much lesser degree than solid organs (liver, spleen etc).
Therefore there is more sound transmitted to structures deep to the fluid filled
structure and the resulting echoes from this deeper tissue are brighter than
those from a similar depth in adjacent solid tissue.

Transducer

Fluid filled structure

Acoustic Enhancement
Echoes brighter than surrounding
similar tissue

Edge shadow

Ü Acoustic enhancement is one of the criteria for classification of

cysts (the others being smooth walls and echo free interior).
ÜThe margins of the area of enhancement are usually sharply
defined and may be parallel or divergent, depending on the
transducer used.

Edge Shadowing

Commonly seen deep to the edges of rounded structures when the velocity of
sound in the rounded structure is different from that of the surrounding tissue.
This results from a combination of reflection and refraction occurring at the edge
of rounded structures.
(See diagram above)

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Reverberation Artifact
The multiple representations in the display, of the same interface. They occur
because of repeated reflections of sound between two interfaces and are
usually generated by high-level mismatch interfaces when the echo amplitude is
very high.

Echoes are placed in the display according to the time taken for their return to
the transducer after their emission. If an echo repeatedly reflects (reverberates)
between two interfaces each successive returning echo will be perceived as
coming from twice the distance as the reflection before, and will be placed at
twice the distance on the display.
Echo c

Echo b

Echo a

ÜReverberation echoes are evenly spaced, because the time for

each additional echo is a multiple of the time of return of the first
echo.
ÜReverberation artifacts are commonly seen in many situations,
such as;
a. Deep to bowel gas
b. Deep to subcutaneous fat and muscle layers, these are easily
seen in a distended urinary bladder but may be masked by the
parenchymal echogenicity of solid organs such as the liver
c. Foreign bodies, multiple reverberations arising from small,
superficial foreign bodies often merge and are displayed as a
“comet tail” artifact

Beam Width Effects

There are several artifacts that occur due to the reality that the ultrasound beam
is not a single line of site, but that the system sees it as such.

This group of artifacts can cause much difficulty to the beginner, in that they
display echoes generated from the edge of the beam, as though they were
generated from the central axis of the beam. These echoes are therefore
incorrectly placed in the image and can give rise to “pseudo pathology”.

This group of artifacts includes:

a. Beam width
b. Side lobe
c. Grating lobe
d. Slice thickness
Common examples of this type of artifact encountered in general
scanning are:
Ü Urinary bladder - “false” echoes within the bladder, arising from
surrounding bowel gas, can be mistaken for pathology

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ÜGall bladder - “pseudo sludge”, echoes within the gall bladder

lumen arising from adjacent bowel or liver
ÜObstetrics - “false” echoes at the side of fetal head or femur
length, can cause inaccurate measurements
The examples above are, obviously, a minute portion of the hundreds of effects
that artifactual echoes of these types can cause.

It must be emphasised that these explanations are simplistic, since the

causes and effects of many of these artifacts are often complex and
variable.

Velocity Artifacts

This group of artifacts occurs because various tissues have velocities different
from the assumed 1540m/sec, which results in incorrect placement of echoes in
the display.

The two main types in this group are;

a. inaccurate depth calculation effects
b. refraction effects

O Examples of these are as follows:

a. Low velocity lesion within the liver - causing displacement of the

diaphragmatic echoes, deep to the lesion

ÜLow velocity in lesion,

compared to surrounding
liver
ÜCauses echoes to take
longer to return to the
Liver transducer
Low Vel
Lesion
ÜTherefore, the
structures deep to the
idney
Rt K lesion are displayed
erroneously deeper in the
image
Diaphragm echo disrupted

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b. Refraction effects such as “lens effect” caused by well developed

rectus abdominus muscles. Results in two images of the same
object, displayed side by side in the transverse plane. E.g. aorta,
early gestation sac.

Assumed line of sight

Actual path of beam

(refracted)

Apparent “double
aorta”
Mirror Image
Structures displayed twice, with one being a mirror of the other. These occur
where there is a strong specular reflector, which acts as a mirror.

Examples of these are:

O Diaphragm/lung interface (show mirroring of the liver texture, above

the diaphragm.
O Bladder/rectum interface, when the rectum is gas filled (bladder wall
is mirrored together with any bladder contents, such as ureterocele,
catheter balloon, mass etc)

The echo from X is displayed at position Y

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Multipath

The placement of echoes in the display is based on the assumption that they
return directly to the transducer after reflection, but this is not always the case.
Echoes can be reflected and refracted. The component of the echo that is
reflected can then reflect off a second interface before returning. This results in
additional path length and time; the second echo is therefore displayed deeper
than the first, along the same line of sight.

Liver

Artifactual “Real” Lesion Rt Kidney

Lesion

Operator Produced Artifacts

Inappropriate setting of gain and TGC and lack of contact can cause confusion;
this is a problem common to beginners and can easily be overcome by careful
manipulation of these controls.

ÜOverall Gain
It is a great temptation to turn up the gain, with the expectation that things
will become clearer! However, over use of gain will merely add noise to
the image.

ÜTGC
Similarly, if one of the TGC slider controls is misaligned, the slope will be
uneven, possibly causing a band of bright or low level echoes within the
field of view.

ÜContact
The most common of all artifacts produced by the beginner, is that of a
lack of adequate contact between the transducer face and the skin
surface. A liberal use of ultrasound gel and reasonable pressure on the
transducer will overcome this.

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PROBLEM SOLVING

Now that we have identified many of the common artifacts occurring in

ultrasound images, we need to learn how to overcome or minimise them and to
definitively recognise them as artifactual echoes and not pathology.

The simple scanning techniques required to contend with artifacts are easily
acquired and can be listed as follows:

ÜTURN DOWN THE GAIN

Ü ALTER ANGULATION OF PROBE AND WATCH THE EFFECT ON
THE ARTIFACT
Ü SCAN IN TWO PLANES
Ü MOVE PATIENT
Ü HAVE PATIENT USE DIFFERENT BREATHING MANOEUVRES
ÜCHANGE TRANSDUCER FREQUENCY
These manoeuvres, taken in order will usually be effective in minimising
artifacts or at least working out what is artifactual and what is real.

At the beginning of the learning curve there is no substitute for practicing

on fellow colleagues or yourself. This will enable the beginner to feel
confident with machine controls and basic scanning techniques, before
being confronted with a patient in an emergency situation.

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SCANNING PRINCIPLES
IMAGE OPTIMISATION & KNOBOLOGY

T hroughout any ultrasound examination the operator should be constantly

monitoring the image quality with a view to improving it. Sometimes
better scanning techniques are required and sometimes optimisation of
the image by changing system controls can cause the necessary improvement
in the image.

A thorough knowledge of the system controls and what effect they have upon
image quality in various scanning scenarios is one of the most fundamental
parts of becoming a good sonographer

T RANSMISSION POWER
Regulates the amount of energy exciting the crystal, and therefore the strength
of the ultrasound beam
ÜThis should be kept to the minimum for required depth
penetration, to minimise exposure

D EPTH
The depth control alters the depth of the field of view. The number of pixels in
the image area is fixed so setting the field of view also sets the number of pixels
used to represent each square centimetre of the patient
Ü Use smallest depth of field necessary to image structure of
interest
Ü Small depth of field - superficial structures
ÜLarge depth of field - deeper structures
FOCUS

Modern transducers use excellent focussing technology to achieve good

resolution throughout the depth of field. Ultrasound systems normally have user
controlled focal zones, giving best definition at the designated depth of focus.

On some systems, it is possible to expand the focal zone by adding more than
one focal point, this will allow focussing over a larger portion of the depth of field
but has the trade off of slowing the frame rate.
Ü Position focal point at area of interest.
Ü Practice using more than one focal zone to watch effect on frame
rate.

TIME G AIN C OMPENSATION (TGC )

As the sound beam passes through the body its strength is attenuated (diminished) by
various factors as discussed above. The echoes returning from deeper structures are
weaker (of lower amplitude) than those from more superficial structures. Applying gain

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 SCANNING PRINCIPLES

to returning echoes from deep structures compensates for this. The operator decides
at what rate this gain will be applied by the use of the TGC controls.

NO TGC Applied TGC Applied

Attenuation occurs Compensates for attenuation at
depth - over time

Slope
Amplitude
(Brightness)

Depth/Time Depth/Time

Bright echoes

Equal amplitude ecoes fromdeep

and superficial structures

Weak echoes have been attenuated

Brightness of echo Brightness of echoes equal

decreases with depth throughout depth of field

NO TGC Applied TGC Applied

Ultrasound systems have user operated TGC controls which can be either slide
pots, with each slider regulating one section of the image or rotary controls
regulating near gain, slope and far gain. (N.B. Some systems only offer near
gain and far gain control.)
ÜTGC adjustments vary with transducer frequency
ÜTGC adjustments vary for each organ/system being imaged
ÜTGC adjustments vary patient body habitus type being imaged
OVERALL GAIN
Amplification of the Received signal
ÜIncreasing the gain does not increase exposure
Ü Affects the whole image equally
Ü Undue increase in gain may obscure subtle changes in texture,
or produce artifactual echoes in fluid filled structures (e.g. gall
bladder, cysts etc)

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D YNAMIC RANGE
The term refers to the range of echoes from strong to weak, available to be
displayed on the monitor at a particular time.
ÜDecreasing dynamic range gives fewer grays and increases
contrast
ÜIncreasing dynamic range gives a wider range of grays and
decreases contrast.
Ü Practice observing changes in dynamic range
ZOOM
This control is used to magnify structures of interest and is best used in real
time or write-zoom mode. Write-zoom affects image quality because the line
density and pixels / unit area are increased. The consequence of these benefits
is a decreased field of view. (Read-zoom is purely a magnification of a particular
part of the field of view and does not affect image resolution)
Ü E.g. easier to measure small luminal diameters
FRAME AVERAGING
Sometimes called persistence or smoothing, this control allows the
accumulation (or averaging) of echo information over two or more frames.
Increasing the amount of frame averaging can enhance subtle textural
differences but can cause blurring of the image and will result in a reduction in
effective frame rate.

Decreasing or removing frame averaging is recommended when scanning

highly mobile tissues (e.g. cardiac structures) since the effective frame rate will
be higher.

C INE MEMORY
Storage of a number of previous image frames on system freeze. The number
of frames retained varies with manufacturer and with memory requirement per
frame stored.

The benefits of cine memory will rapidly become apparent on use of the control;
the saved sequence of frames can be reviewed at will, manipulated and
imaged. This can be particularly useful when scanning the very young or the
very old patient, who may be uncooperative.

B -MODE COLOUR
Many modern systems allow the echoes (normally displayed in shades of gray)
to be displayed in hues of colour. This can be useful in apparent enhancement
of contrast resolution, since the human eye can more readily discern small
changes in colour hue than in shades of gray. The choice of colour map
appears to be quite subjective; most manufacturers offer a range of different
maps for individual preference.
Ü Useful practically in many different types of scan
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TERMINOLOGY
There are other controls available on ultrasound systems, many of which are
different depending on manufacturers’ range of technologies and many of which
are labeled using different terms but in fact have the same operational use. Two
terms that are used frequently in discussion of ultrasound image production are
pre and post processing.

O Pre-processing controls are those that involve manipulation of echo data

before it is stored in the scan converter memory.. Those that can be
changed by the operator are TGC, FOV, Frame Averaging, Dynamic
Range and digitisation. Pre-processing controls are those that require re-
scanning of the image with a different control setting if the image produced
is not suitable or satisfactory.
O Post-processing controls are those that involve manipulation of the data
after it has been stored in memory, such as greyscale maps, B-colour etc.
The original data can be restored after manipulation with post-processing
controls.

OTHER FACTORS AFFECTING THE IMAGE

FREQUENCY
Frequency is defined as the number of ultrasound cycles generated per unit of
time.
E.g. 1MHz = 1 million cycles per second.

Many systems have transducers with the capability of being switched from one
frequency to another. (“Wide bandwidth”, “Frequency domain imaging
transducers” etc) The technology involved in producing these transducers
varies between manufacturers and the precise physics involved can be learned
from pertinent texts.

The important practical facts to note about the frequency of a transducer are
how changing frequency affects image acquisition and resolution.
Ü Higher frequency - greater resolution, poorer penetration
ÜLower frequency - poorer resolution, greater penetration
Ü Use the highest frequency possible to reach the necessary
depth.
e.g. Heart - 2.5-3.5 MHz
Abdo - 3.5 - 5.0 MHz
Pancreas, G.B. - 5.0 MHz
Foreign bodies etc 7.5 - 12.00 MHz

ANGLE OF INCIDENCE
The largest reflection of sound will occur at 90° to an interface; therefore the
best images will result from a sound beam projected at 90° to the main area of
interest.

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PRACTICAL PHYSICS OF SPECTRAL & COLOUR DOPPLER

INTRODUCTION

It is essential to understand that both Spectral and Colour Doppler operate

under the same physical laws. So the statement, “Colour is Doppler and
Doppler is Colour”, is accurate and should always be remembered. Therefore
one should have a sound understanding of the principles of spectral Doppler,
before progressing to colour Doppler.

It is important to understand that these two technologies share controls,

terminology, limitations and artifacts and we will discuss these along the way.

T HE D OPPLER EQUATION

The basis of all colour and spectral Doppler physics is encompassed in the Doppler equation.

2foV
f = (cos φ)
c

Where:
· f = The detected Doppler Frequency Shift
· fo = Initial Doppler Frequency
· V = Velocity of Moving Blood
· c = Speed of Sound in Tissue
· φ = The Angle between the ultrasound beam and the flow direction

All this means is that the initial (or, incident) frequency of the sound beam is
different from that which is received from a moving reflector (blood) and that
difference varies with
· the velocity of the moving reflector
· the angle between the ultrasound beam and the flow
· Initial (operating) frequency

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 PRACTICAL PHYSICS OF SPECTRAL & C OLOUR DOPPLER

D IRECTION AND THE DOPPLER EFFECT

Using the Doppler effect we can indicate the direction of the moving reflector.
A practical, well-known description of the Doppler effect is that of the change in
pitch of a train whistle or siren as they come towards or away from you when
you are standing still. The pitch increases as the train is coming towards you
and decreases as it is moving away.

This, of course, holds true for frequency shifts detected by an ultrasound

machine when the moving reflector, blood, is moving in respect to the
transducer.

If the blood is moving towards the transducer then the received frequency will
be higher than the initial frequency. Conversely, if the blood is moving away
from the transducer, then the received frequency will be lower than the initial
frequency.

However, if the blood is travelling at 90 degrees to the transducer then the

received frequency will be equal to the initial frequency and therefore there will
be no discernible frequency shift.

C ONSEQUENCES OF DOPPLER ANGLE C HANGES

As we have seen in the Doppler equation, the dependence on the Doppler

angle is in the form of a cosine. For a given flow, the greater the Doppler angle
is, the lesser the Doppler shift is. A zero degree angle gives the greatest
Doppler shift and at ninety degrees the Doppler shift is reduced to nil.
90
60 · With constant flow, as the Doppler
Angle increases, the frequency of
40 the echo Doppler shift decreases

· The direction of the arrows

indicates the beam’s direction. The
20
length of the arrows indicates the
magnitude of the Doppler shift.
FLOW

Flow speed calculations based on the Doppler shift measurements can only be
accomplished correctly with knowledge of the Doppler angle. It is obviously
important to estimate this angle as accurately as possible. This is normally
accomplished by placing the Doppler angle bar, on the anatomical display, so
that it is parallel to the assumed direction of flow. In straight vessels with no
flow obstruction this can be assumed to be parallel to the vessel wall, however,
in tortuous or obstructed vessels, this may not be the case.

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 PRACTICAL PHYSICS OF SPECTRAL & C OLOUR DOPPLER

Examples:
Example 1 Example 2
Initial Frequency - 1MHz Initial Frequency - 1MHz
Speed of Sound - 1600 m/s Speed of Sound - 1600 m/s
Velocity of reflector - 16m/s Velocity of reflector - 16m/s
Angle - 0 deg Angle - 6 0 deg
Doppler shift - 0.02MHz Doppler shift - 0.01MHz

C ONSEQUENCES OF INITIAL D OPPLER FREQUENCY C HANGES

We must also remember the proportional relationship shown in the Doppler

equation of the initial, or operating, frequency of the transducer and the Doppler
shift measured by the system.

Doppler shifts measured for a given flow in a vessel, using two transducers of
3MHz and 6MHz would be different. The Doppler shift from the higher
frequency transducer would be double that of the lower frequency transducer.

In the clinical situation it is then important to select the transducer frequency

suitable for the particular application. In venous work, we need a higher
frequency to detect the low velocities which will produce small frequency shifts.

Example 3 Example 4
Initial Frequency - 1MHz Initial Frequency - 2MHz
Speed of Sound - 1600 m/s Speed of Sound - 1600 m/s
Velocity of reflector - 40m/s Velocity of reflector - 40m/s
Angle - 0 deg Angle - 0 deg
Doppler shift - 0 .05MHz Doppler shift - 0.10MHz

D OPPLER INSTRUMENTATION
There are three types of Doppler equipment used for the detection of flow in the
body, continuous wave and pulsed wave spectral instruments and colour
mapping instruments.

C ONTINUOUS WAVE DOPPLER

These instruments include a continuous wave generator and a receiver that
detects the change in frequency (Doppler shift) which results from reflector
motion. The information received is presented as an audible signal and a
spectral display. A continuous wave instrument detects flow occurring
anywhere in the overlapping region of the transmitting and receiving beams.
Because there is no depth range gate, the signals can be very confusing and
include a broad range of frequency shifts.

Advantage Disadvantage
· Excellent detection of high · No range gate location
velocity flows
· No aliasing limits · Spectral broadening

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 PRACTICAL PHYSICS OF SPECTRAL & C OLOUR DOPPLER

PULSED WAVE
The transducer assembly in these instruments functions both as a transmitter
and a receiver. Once the magnitude and direction of the Doppler shift have
been derived they are presented as both audible and spectral displays. The
receiver gate (sample volume) is set by the operator at a given depth on the
ultrasound display and only echoes arising from moving reflectors at that depth
are displayed as a spectrum.

The upper limit of the Doppler shifts which can be detected by a pulsed Doppler
system is equal to one half of the number of pulses per second (Pulse
Repetition Frequency), e.g. PRF - 1000Hz = maximum detectable Doppler shift
of 500Hz. When this limit is exceeded, aliasing occurs. (This limit is sometimes
known as the Nyquist Limit.) Thus higher PRFs permit higher Doppler shifts to
be detected.

Advantage Disadvantage
· Single sample volume · Aliasing - dependent on the PRF
· Accurate range location
· Quantitative spectral analysis
SIGNAL PROCESSING - PUTTING IT ALL TOGETHER!
A pulsed Doppler system must receive the last echo from each pulse before it
transmits the next burst. The system automatically calculates the round trip
time of this burst, by knowing where the sample volume has been placed, and
analyses the signals at that point in time.

Using a method called Fast Fourier Transform, which rapidly assesses all the
different frequency shifts from the sample site, the system produces a spectral
display on the monitor. A mathematical algorithm then completes the Doppler
equation, correcting for the angle between the blood flow and the sound beam,
converting the frequency shifts (KHz) to a velocity (M/s). Most modern systems
will not complete this conversion if the Doppler angle is greater than 70
degrees, since the resulting velocity would have a large degree of inaccuracy.

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 PRACTICAL PHYSICS OF SPECTRAL & C OLOUR DOPPLER

C OLOUR DOPPLER IMAGING

Colour Doppler is a display of mean frequency. Data from hundreds or
thousands of sample volumes is processed, using a system called
autocorrelation. A very simple explanation of this is that all the frequency shift
data obtained from these multiple sample volumes is analysed for mean
frequency, amplitude and turbulence.

This allows us to use colour Doppler information to quickly appreciate

haemodynamic events occurring in the region of interest in a qualitative manner,
such as -
· Existence of flow
· Direction of flow
· Existence of turbulent flow
thus providing a “road map” for pulsed Doppler spectral analysis.

Perhaps the most important point to remember is that colour Doppler is a

QUALITATIVE analysis of data and does not provide velocity information.

C OLOUR DISPLAY
A colour wheel or colour bar is used in most equipment to display the direction,
amplitude and turbulence data in a colour Doppler signal. These displays
indicate direction of flow (positive or negative frequency shift) as red or blue,
dependant upon allocation or encoding by the operator. The highest amplitude
is displayed as the brightest colours with areas of turbulence being displayed as
green (the brightest green being the most severe turbulence).

R EGION OF INTEREST BOX (R OI)

The size of the colour box should be adjusted to optimise the frame rate, but still
allow a suitable area of the field of view to be covered. The box may be adjusted
in:
- width
- height
- depth into the patient

By reducing the width of the box, fewer colour

lines of sight are required (and remember that
each of these lines requires several pulses). By
reducing the width, each frame can be completed
in much less time therefore significantly increasing
the frame rate.

If the height of the box is reduced but the

width is maintained, the same number of
beam paths is still required; therefore the
effect on frame rate is minimal.

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 PRACTICAL PHYSICS OF SPECTRAL & C OLOUR DOPPLER

If the depth of the colour box in the patient is

reduced, then for each pulse sent into the
patient, the computer does not have to wait
as long to receive the echoes. Each line of
sight can then be completed in a shorter
period of time, making the entire frame
completion time somewhat faster. Frame rate
therefore increases.

C ONTROLS
Spectral and colour Doppler controls are often not properly understood by the operator
because the modern systems available have excellent applications software to set the
parameters for differing flow situations within the body. Most of the time, these set ups
are more than adequate; however, it is necessary to understand the functions of these
controls in order to optimise the system for individual, difficult cases. Ultrasound
equipment manufacturers have different names for many of these controls, so it is also
important to find out what terms are used in your particular system.

PULSE REPETITION FREQUENCY (PRF)

Other terms for this are flow rate or scale. This determines the sampling time that is
required to process the Doppler information. Since low flow must be sampled for a
longer period of time to accurately analyse the information for colour display, low PRF
must be selected for these situations. Higher flows can be sampled more quickly so
high PRF can be selected in these situations.

Whilst the system preset will be adequate as a beginning don’t forget that changes may
be necessary during an examination. E.g. Vertebral flow is often slower than common
carotid flow - lowering the PRF when looking for vertebral arteries in a carotid exam
can assist in speedy recognition of the vertebral artery.
FILTERS
There are numerous terms used, such as high pass
filter (HPF), wall filter or thump filter. Their function
is to eliminate strong, low frequency Doppler shifts
arising from tissue or vessel wall motion. Another
way of remembering this function is to think of them
as “electronic erasers “, in that the filter will
eliminate or erase any frequency below that set.

Doppler shifts (= colour signals) are produced not

only from blood flow, but also from any other
moving structure, including solid tissue.

Tissue motion is very slow velocity, but the

Doppler signals are large amplitude compared to
blood flow signals because of the large
reflections from the tissue interfaces. These low
velocity signals cause colour flashes to occur in
the presence of moving tissue, and these can
greatly degrade the quality of the colour image.

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 PRACTICAL PHYSICS OF SPECTRAL & C OLOUR DOPPLER

The wall filter causes the computer to completely ignore Doppler shifts
(= velocity) below a set limit.

Because vessel walls are a major cause of these unwanted signals, the filter to
remove them was called a “wall filter”. However these filters will remove all
frequency shifts below the selected limit, whether they are caused by wall motion,
adjacent soft tissue movement or blood flow.

Although prudent use of a wall filter will produce a more diagnostic colour
image, overuse (i.e. setting the cutoff limit too high), may remove significant
blood flow echoes, and in extreme cases all flow representation.

When attempting to visualise slow velocity flow such as that seen in peripheral
veins, the wall filter must be set very low to prevent removal of the echoes. In
this case a conscious effort must be made to minimise tissue movement by
careful transducer and hand movements.

In fast flow areas, such as arteries, increase the filter setting to produce an
image with little colour produced over the vessel walls or adjacent tissue.

C OLOUR & SPECTRAL DOPPLER INVERT

This simply allows the operator to make a negative spectral Doppler shift
appear above the baseline, which can be helpful when interrogating a vessel
from differing Doppler angles.

In colour, this allows arteries to be displayed in red and veins in blue, regardless
of the angle of interrogation. In carotid or peripheral studies, where the vessels
are mostly straight, this is fairly simple to understand and control but care must
be taken in abdominal studies, where the vessels are often tortuous. The
operator must have a good knowledge of vascular anatomy to avoid interpretive
mistakes.

STEERING
Spectral Doppler - As we have seen, a 0 degree interrogation angle will produce
the highest frequency shift. Steering allows us to place the sample volume at
the best angle possible in a particular vessel and will provide directional
information.
Colour Doppler - Steering the ROI will provide information on the direction of
flow with respect to the transducer; however, steering also reduces the
sensitivity of the system (due to refraction, scattering and aperture reduction).
Therefore, when small vessel flow detection is necessary e.g. Thyroid or
Testicular studies, the ROI should not be steered, allowing optimal system
sensitivity.

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 PRACTICAL PHYSICS OF SPECTRAL & C OLOUR DOPPLER

C OLOUR QUALITY
Other terms for this are packet size or length and ensemble length or sensitivity.
This is simply the number of times and for how long, the system samples each
line of sight in the ROI. Higher numbers will require longer sampling time and
therefore reduce frame rate, but will result in a more homogeneous colour
display. Lower numbers will result in higher frame rates but more pixilated
colour, with a more accurate display of haemodynamic changes.

It is up to the operator to decide the quality of the colour display for each
application and patient.

B -SCAN/C OLOUR PRIORITY

This is a decision circuit, which allows the system to overlay colour information
on areas of the greyscale image where there is no greyscale information. (That
is to say, not over pixels displaying greyscale information) In large vessels, this
is simple, since it is easy for the system to differentiate between the vessel and
surrounding tissue. However, in vessels that are too small to be resolved on the
greyscale image (testis), the moving blood detected by the Doppler cannot be
written as colour in the vessels since the system does not “see” them as “black”.

By reducing the priority of greyscale in the decision circuit, the operator can
override the preset levels and allow this colour data to be written over pixels
containing greyscale information.

ARTIFACTS

As in any other ultrasound modality, spectral and colour Doppler both have
artifacts to be used or overcome. Doppler artifacts tend to be common to both
colour and spectral, being displayed in different formats.

ALIASING
This is probably the most common artifact occurring in Doppler studies. The
important thing to remember here is that aliasing is NOT a disease indicator. It
simply means that the speed of the flow being examined is faster than half of
the PRF set. Colour aliasing can be useful in certain applications to map
changes in frequency shift, in a vessel with blood flowing at a constant angle
with respect to the transducer.

In colour, the aliasing will be displayed as the wrong colour. Colour changing
from red, through yellow and green, to blue is caused by aliasing. Colour
changing from red, through black, to blue is caused by a change in direction.

In spectral Doppler, aliasing will be displayed by spectral data being wrapped

around the base line. Increasing the PRF will “unwrap” the spectrum and display
it in the correct direction, either above or below the baseline.

Switching to a lower Doppler frequency will also serve to decrease aliasing.

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 PRACTICAL PHYSICS OF SPECTRAL & C OLOUR DOPPLER

MIRROR IMAGE ARTIFACT

Presents information as flow on both sides of the baseline in spectral Doppler.

This can happen when the Doppler gain is set too high or when the Doppler
angle is near 90 degrees. Using electronic array probes, this artifact can
become apparent when the Doppler cursor is positioned too close to the centre
of the crystal.

To minimise this artifact in spectral Doppler:

· Lower Doppler gain

· Lower Doppler angle of incidence
· Reposition probe so that cursor is between the middle and edge of the crystal

Mirror imaging can occur in colour Doppler; being depicted as opposing colours
in unidirectional flow or as a mirror of a vessel on the opposite side of a
particularly strong reflector (Diaphragm).

· Correct angle selection will minimise colour mirroring.

ANGLE OF INCIDENCE

A vessel curving through the colour ROI makes it possible for the Doppler to
interrogate unidirectional flow in two different directions, towards the transducer
and away. This commonly occurs when curving vessels are interrogated at or
near 90 degrees.

· Correction of the angle of incidence will eliminate this artifact

In curving or tortuous vessels changes in the angle of incidence towards 0

degrees along the vessel may display frequency shifts that appear accelerated
or even aliased. This may be misinterpreted as an area of increase in velocity,
but is, in fact, artifactual.

· Understanding of the physics of the effect of the angle of incidence on colour

display will eliminate misinterpretation of this artifact.

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PROBE MANIPULATION TECHNIQUES

O
nce the machine controls have been mastered, scanning skills need to
be acquired in order to continue upward on the learning curve. The
beginner can often find manipulation of the transducer a difficult and
painful process (the fingers and wrist become locked and sore!!).

Recognising the orientation of the transducer is probably the most important

factor to begin with. Most transducer manufacturers provide an orientation
mark, usually a small raised bump or light on one side of the transducer
handle. In general, this mark should be towards the patient’s head for sagittal
sections and towards the patient’s right for transverse sections.

The transducer should be used as an extension of your hand and visualised

as a torch, with the ultrasound beam as the light emanating from the torch.
The anatomy must be visualised as three-dimensional and not just the two-
dimensional view seen on the monitor, point the transducer at the organ you
wish to image, remembering the three dimensions.

The probe should be held with the operator’s fingers close to the transducer
face and with the little finger resting on the patient’s skin, so that maximum
control is exerted. In this way, the transducer will not slide off the scan plane
needed and can be kept steady on the patient’s skin, at the correct angle.
ÜOrientate the transducer correctly
ÜRemember the body is three-dimensional anatomy
ÜUse the ultrasound beam as a torch, pointing at what you need
to see
ÜHold the probe so that the fingers control the transducer face
properly

SCANNING TECHNIQUES
1. Work Station

Operator comfort is an important factor in successful image acquisition. The

operator should be positioned so that the forearm and hand are gently resting
on the patient, with the spine erect and eyes at the level of the system
monitor.
ÜScanning can be undertaken either seated (adjustable chair
with wheels) or standing, depending on the height of the operator.
ÜIf the patient trolley is adjustable, adjust the height to suit the
operator.

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Whilst this is not always possible in venous scans, the benefits accrued in
operator comfort and improved scans are well worth the few moments it takes
to set up a reasonably ergonomic workstation for each scanning situation.

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 INSTRUMENTATION

2. ULTRASOUND G EL
For a variety of reasons, it is important to use sufficient gel over the proposed
scanning area. A common mistake made by beginners is to use insufficient
gel, thereby making poor contact with the skin surface (producing artifacts and
poor imaging) and reducing the mobility of the transducer face over the skin
(producing patient discomfort and operator frustration).
ÜToo much gel is far better than not enough!
ÜSpread out the gel over the proposed scanning area, before
beginning your survey scan

3. SURVEY SCAN
Always perform a swift survey of the area in question, before focussing on the
point of clinical question. This will serve to orient you to the anatomy under
review and identify good sonographic “windows”.
ÜPerform a survey scan first
SONOGRAPHIC “WINDOWS”
A sonographic window can be described as a path for the sound beam into
the body, to reach the organ in question, avoiding areas of bone, bowel, or
lung. An example of this is:

ÜUsing muscle bellies to view veins from different approaches &

to avoid shadowing from ligaments or fascial planes.

A large part of the sonographic art is an intuitive grasp of finding good

sonographic windows. Visualising the body in three dimensions and applying
logical thought to the best approach for a particular organ, vessel or lesion will
quickly lead to this intuitive grasp.

5. T RANSDUCER MOVEMENT
Transducer movements should be smooth free flowing, allowing proper time
for the operator to view the real time image on the monitor without constant
checking of transducer position. When the area of interest has been reviewed
and the sonographic window decided upon, the transducer movements should
be slowed and small movements made in one plane at a time, otherwise it
easy to become confused and lose sight of the organ, vessel or lesion in
question.

Transducer movements are;

1. Rotate
2. Fan (with long axis of transducer)
3. Heel / Toe (H=non-marker / T=marker)
4. Slide (towards or away from marker)

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ÜMake one movement at a time, with logical forethought

ÜSlow movements down when focusing on area of
interest

GRADED C OMPRESSION

The use of firm pressure on the transducer can significantly improve images
of deeper structure by several means:
a. decreasing the distance of the target to the transducer, thus bringing
the target into the main focal area of the beam or
b. allowing the use of higher frequency transducers or
c. pushing loops of gas filled bowel out of the field
d. improving skin/transducer contact
e. minimising some artifacts

The emphasis should be on gradual, graded compression - since this is well

tolerated by most patients, even those experiencing significant pain.

ÜUse graded compression, increasing and decreasing pressure

gradually
8. MULTIPLE SCAN PLANES

Structures should always be viewed in at least two different scanning planes,

with longitudinal and transverse sections being the minimum. It is preferable
to view from two different approaches as well, e.g. anterior & coronal. This
can easily resolve confusion concerning the nature of some structures e.g.
cyst versus tube, aorta versus inferior vena cava.
ÜAlways view structures from at least two different approaches
and in two different planes.

DYNAMIC TECHNIQUES

Holding the transducer steady and watching muscles & tendons move in and
out of the field as the patient gently moves can often elicit a large amount of
information as to the best window to use.

THE T RANSDUCER AS A PALPATION T OOL

Using the face of the transducer to gently palpate an area of pain will often
elicit clinically useful information, e.g. acute pain on direct palpation of
superficial thrombophlebitis. The benefit accrued from this is being able to
view the area being palpated to be certain of cause of pain.

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PROTOCOLS AS A USEFUL TOOL

Departmental protocols are an extremely useful tool during the learning curve
and should be used regularly until they are second nature. A simple way to
enhance memory of different scanning techniques is to make up your own
protocols using your own words.

©AIU 38