008.

Advances in USG

Dr. Sudip Humagain

3rd year resident
25-02-2079
Contents

• Composition of a real-time B-mode ultrasound system.

• Overview of the developments in ultrasound and brief history
• Advances and its diagnostic and therapeutic role

• Almost 25% of all imaging studies worldwide are ultrasound examinations.

 • Sound is mechanical energy traveling through matter
as a wave producing alternating compression and
rarefaction.
Bulk modulus:
amplitude of reflected energy is used to generate
ultrasound images in B MODE

ELASTOGRAPHY:
Transverse wave: determined by Young modulus, a
measure of tissue stiffness or elasticity

Frequency shifts in the backscattered ultrasound

provide information relating to moving targets such
as blood IN DOPPLER
 Acoustic Impedance: Is resistance to
travel of sound wave by interface of tissue.
Propagation velocity: acoustic interface:
Depend upon density The junction of tissues or materials with
and stiffness different physical properties produces
INTERFACE
amount of reflection or backscatter is
determined by the difference in the acoustic
impedances of the materials forming the
interface.
absorption,
scattering, and reflection.
nature of the attenuating
medium
basic components:
Transmitter or pulser: to energize the transducer
Ultrasound transducer:
Receiver and processor:detect and amplify reflected
echos
Dizitizer: convert analogue signal into digital
signal
scan converter: read into the image memory
Display: image or data in a form suitable for analysis
and interpretation
Brief history
• 1794: navigation of flying bats in the dark, employed sound rather than light
to orient themselves .
• 1880: Galton created and produced the apparatus that was able to produce
the sound waves of a frequency of 40 hertz.
• Curie brothers: discovered the piezoelectric effect and inverse piezoelectric
effect,
• sinking of the Titanic in 1912: scientific efforts were instigated to develop a
system to visualize underwater structures
• during the First World War: unsuccessful attempt make to visualize
underwater structures
• 1947-1948, Karl Dussik, an Austrian physician, and his brother Friederick, a
physicist, introduced hyperphonography, a technique which used ultrasound
to visualize the cerebral ventricles
• George Ludwig : in 1949: research into gallstones embedded in soft
tissues :lay the foundations for the later successful use of ultrasound in
medical practice.
• Ian Donald: in 1956: ultrasound in diagnostic and medicine , A-mode
(amplitude mode)
• Brown : “two-dimensional compound scanner”, to visualize the density of the
tissue, which is often referred to as the turning point in the application of
ultrasound in medicine.
• 1963 : B mode (“brightness mode”)
• 1970s: the “grey scale”the real-time ultrasound scanners
• progressed from cumbersome and expensive B-mode gantry systems to
hand-held devices
• fully digital, improves the SNR, high machine's performance with respect
to beam formation, signal processing, image display and archiving.
• used to measure the elastic and dynamic properties of tissues.
• microbubble contrast agents and effective vascular echo enhancers
• potential as tissue-specific and targeted therapeutic agents.
• High intensity focused ultrasound (HIFU) : therapeutic application
DEVELOPMENTS IN TRANSDUCER MATERIAL AND CONSTRUCTION

Future transducer developments:

array configurations: concentric ring array/intracavitary array
transducer materials and higher frequency probes,
higher element densities, innovative geometries,
advances is beam forming and improved ferroelectrics

Ultrasound transducer:
Transducer efficacy: limited range of frequencies over which they are effective.
bandwidth : width of the frequency response at half maximum transducer output.
A large bandwidth improves contrast and spatial resolution (both axial and lateral).
Multifrequency single probe: essential for harmonic imaging
Lead zirconate titanate (PZT) ferroelectric material : combine PZT
with a material of low acoustic
impedance such as epoxy resin to
form a composite.
Ferroelectric relaxor
Low electromechanical coupling increase in bandwidth:
coefficient

high acoustic impedance

high reflection coefficient at the front
and back surfaces producing multiple
'ringing' producing reverberation matching layers:
artifacts
a maximizing the
Low transmission
coefficient :decreases sensitivity to
electromechanical coupling
low echos coefficient (a measure of the
efficiency of conversion of
sound to electrical energy.
 ARRAY CONFIGURATIONS

Quadratic multi-dimensional arrays, known as 1.5D and

2D arrays:
enable electronic focusing of the ultrasound beam in
the z plane (slice thickness or elevation plane)
improves spatial and contrast resolution.
2D arrays: electronically steering the beam in any
plane to produce a real-time volumetric image without
moving the probe.
complex connections to the probe elements and
computing power required to deal with the signal from a
2D matrix means
 DIGITAL ULTRASONIC IMAGING
• Digital technology has revolutionized all stages of US systems
• use of application specific integrated circuits (ASICs) whereby one
superchip can replace several boards of electronics.
• the evolution of small portable scanners with high resolution grey-scale,
power and pulsed wave Doppler, tissue harmonic imaging and image cine
memory.
Digital Beam Forming
• Digital control of the transducer array:
• used to steer the US beam and allows dynamic changes in
both focusing and aperture to be made while receiving US
echoes.
• used to improve image quality, the size of the field of view or the
frame rate.
• higher spatial resolution and reducing artifacts.
• improves image contrast.
Spatial Compounding
• uses electronic beam steering to acquire
overlapping scans (3-9 frames) of an object from
different angles.

• averaged to produce a real-time compound image

of improved quality with reduction in speckle
 Coded Excitation Mode
• transmitted pulse is digitally encoded and the
frequency response of the receiver is optimized
according to the application and target depth.
• transmit pulse : modified by varying the frequency
or amplitude.
• 'code can be looked for in the returning echoes so
allowing weak echoes to be distinguished from
background noise.
• The advantages are that higher frequencies
improve spatial and contrast resolution down to
greater depths.
Automatic Gain Compensation Modes

• Automatic gain compensation modes set the

correct gain in 2D at any point across the
image with one button press.
• achieved by the processor analysing the
distribution of grey levels in each part of the
image and adjusting the
grey level of each pixel to optimize local
contrast.
 Photopic Ultrasound Imaging
• real-time or post-processing technology which takes advantage of the
natural perception of light in the eye to optimize grey-scale tissue
differentiation.
• Automatic optimization systems are also available
• improves image contrast and may be particularly useful in musculoskeletal
applications, such as evaluation for neuromas and plantar fasciitis where lesion
contrast is low.
 EXTENDED FIELD OF VIEW(EFOV)

• produce high resolution EFOV images in grey-scale or Doppler

Advantage:
• lesions and their anatomical relationships depicted well.
• allows measurements of large structures
EFOV is most useful for superficial structures such as the neck, scrotum, musculoskeletal
system and breast.
THREE-DIMENSIONAL (3D) ULTRASOUND

• US has lagged behind both CT and MR in 3D imaging

• based on reconstruction algorithms and dependent on high-quality
2D data which have been limited by problems such as speckle,
grating lobe, clutter and other artifacts.
• Recent developments: harmonic imaging. non-linear signal
processing and 2D matrix array transducers have reduced these
problems.
• Volume data : display as series of multi-planar reformats (MPR),
• volume rendered image allowing optimal appreciation of the relative
position of structures, including flowing blood, within that volume.
• Clinical applications :
• fetal face and skeleton and in volume measurements in
obstetrics and oncology.
• In the interventional setting,
to guide radioactive seed implants in the prostate.
 insertion of transjugular intrahepatic portocaval shunts
 for breast biopsy.
while a stereotactic system : developed for needle delivery
using electromagnetic position sensors.
• 4D US will find applications in echocardiography and in needle
guidance systems.( time domain): continuous acquisition of 3D.
Tissue harmonic imaging
• Compresssion travel faster
• rarefraction travel slower=
distortion of sinusoidal wave
• non-linear propagation of a
sound wave as it passes
through tissue

Harmonic are created in media,

Multiple of fundamental frequency
Narrower beam so higher spatial
resolution
• Harmonics beam is narrow ---better lateral resolution
• Grating lobes artifact eliminated as only strong beam can create harmonics
• Near field artifacts and sound distortion cannot occur.
• Reverberation artifact reduced.
• differentiating cystic from solid hepatic lesions
• improves detection of stones in the gallbladder & biliary tree
• simple from complex renal cysts.

• Pulse inversion harmonics /power modulation harmonic/harmonic band

filtering
• disadvantage: slightly decrease frame rate so degrade temporal resolution
ALTERNATIVE ULTRASONIC IMAGING METHODS

• number of ultrasonic imaging methods that are currently being

evaluated utilize physical behaviour of tissue other than that
used in B-mode US: bulk modulus).
Elastography: palpation by imaging
The stiffness (Young's modulus) of tissue tends to alter (usually increase)
with disease and can be imaged by measuring the tissue's distortion (strain)
under an applied stress (e.g. compression via the transducer).

Tissue stiffness or elasticity:

expressed by Young Modulus –
the ratio of the compression
pressure( stress ) and the resulting
deformation (strain)

Stress: force applied (pas)

Strain: displacement along the direction of
stress
Shear: deformation perpendicular to stress.
Strain Elastography/static
• Stress: manual compression by probe ( static)
• Measurement strain(Acquire both
precompression and on compression data )

strain Stiff tissue Soft tissue

displacemnet Less More
Gray scale dark Bright
Color coded image Blue Red/green
( vendors)
Strain ratio/ fat Higher Lower
lesion ratio
 Shear Wave Elastography/dynamic
• Longitudinal tissue compression results in the generation of
transverse shear waves.
• Stress: Ultrasound pulse (Dynamic force applied).
• Tracking pulses to track shear wave.
• Track the shear wave via multiple sound pulses.- quantitative
• Color coded images
• Measurement of shear wave velocity ( proportional to
stiffness)
• Fibroscan.
• ARIF( Acoustic radiation force impulse)

• Note: shear wave is slower compared to compression

wave( usg pulse) so can be tracked.
quantitative color elastograms
Subcutaneous tissue: blue
Tendon: green
Bone : red
50MHZ

FIBROSCAN
 strain shear

availability wide limited

Quality image excellent good

Depth Good Limited 6cm

Quantification limited excellent

Diffuse/focal focal Focal/diffuse

• future: poroelastography: fluid movement in interstitium.

• Axial shear strain elastography: measures degree of binding of mass

to surrounding tissue
Vibro-acoustography
• another method for imaging tissue elasticity.
• Two ultrasound beams with slightly different frequencies are focused
on an object of interest.
The resulting interference causes part of or the whole object to vibrate
at a low frequency which is detected by a microphone (hydrophone).
• By scanning the two focused beams across the object an image is
built up.
• This technique appears to be particularly adept at delineating calcium
deposits within tissues, such as breast micro-calcifications
 Acoustic Microscopy
• High frequency transducers: high bandwidth (>
100%) but relatively poor sensitivity.
• Acoustic microscopy: utilizes a number of acoustic
tissue characteristics such as attenuation and
Red, necrosis; green, apoptosis; blue, nucleus
impedance to visualize cellular stiffness, viscosity, and
size.
• Applications in ophthalmology:
• the diagnosis and treatment of ocular diseases ranging
from tumours, retinal and vitreous conditions and
anterior chamber disorders such as glaucoma.
• dermatological conditions stomach tumours and the
kidney .
• possible to insert an ultra-high frequency micro-
transducer, via a line bore needle into tissue and obtain
in situ histology.
Photoacoustic imaging
• near infrared light pulse: leads the thermal
expansion of tissue: generates ultrasound that
• can be detected by the transducers
of :reconstructed into images showing the optical
absorption of tissues.

endogenous molecules such as hemoglobin or melanin, or exogenously delivered contrast agents

tumor angiogenesis monitoring, blood oxygenation mapping, functional brain imaging, skin melanoma
detection,
dedicated breast scanner showed differences in optical absorption between benign and malignant
lesions in the breast
early detection of rheumatoid arthritis
imaging lipids in atherosclerotic plaques to assess their vulnerability
ENDOLUMINAL US
• miniaturization of transducers allowed interrogation of lumina.
• nanoprobes can be inserted through a 21 G needle and catheters.
• Applications : gastrointestinal tract, biliary system. urogenital tract and
tracheobronchial tree
• In the future, therapy may be administered via this route.
• In intravascular US (IVUS): the vessel wall is displayed at 10- 30 MHz and this has
been applied to the coronary and carotid arteries allowing plaque characterization,
calculation of blood flow and shear wall stresses IVUS may also be used to guide and
monitor angioplasty.
MICROBUBBLE CONTRAST AGENTS
• Microbubbles <10 um – cross capillary beds
• are safe, effective echo enhancers.
• synthesized by mechanical agitation, sonication, or the use of microfluidic devices
• Microbubbles: consist of a gas (air or a perfluorocarbon) stabilized by a shell
(denatured albumin, phospholipid or surfactant or cyanoacrylate).
• micro-bubbles remain within the vascular compartment
• some agents have been to shown to exhibit a hepatosplenic tissue-specific phase
• augmentation of the ultrasound signal for several minutes alter an intravenous bolus,
or 15- 20 minutes after an infusion with enhancement in grey-scale and Doppler
signals of up to 25 dB (greater than 300 fold increase).
• Levovist: galactose microcrystals stabilized by a trace of palmitic acid.
Diagram illustrating development stage of microbubbles,
nanobubbles, and nanodroplets for diagnostic and
therapeutic purposes.
 Interactions of Microbubbles with Ultrasound Waves:
• Complex
• Since a microbubble is more compressible than soft tissue:
• At low acoustic power
• (<100 KPa): compression = expansion. (linear behaviour) and not altered incident
frequency
• 100 Kpa-1 MPa: compression< expansion: non-linear interactions.
• 1-20 MHz: Microbubbles resonate : emitting harmonic signals at multiples (or fractions)
of the insonating frequency: signature or fingerprint unique to that agent.
• still higher powers: non-line interaction: better contrast with surrounding tissue.
HARMONIC IMAGING
• used to image US contrast agents by tuning the receiver to listen to a
band of frequencies centred on a harmonic signal
• usually the second harmonic 2 f0, where fo is the centre frequency of the
transmitted pulse.
• to image flow in vessels down to 100 um in diameter
CLINICAL APPLICATIONS

Non-vascular Uses:
• Sonosalpingography: fallopian tube
patency: Contrast enhanced mode (a) showing
uterine cavity, (b) showing the tube
introduced iinto the uterine cavity
and noting its passage along the
tubes
• vesico-ureteric reflux: bladder and
the renal pelvis and ureters are
study.
 Vascular Uses:

• echocardiography :
• ventricular enhancement and delineation of endocardial borders
• improved detection of wall motion abnormalities
• left ventricular volume, ejection fraction, diagnosis and grading of valvular disease,
thrombus detection, aortic dissection, detection o complications of myocardial infarction
such as ventricular rupture and aneurysm formation.

In stress echocardiography:
• accurate assessment of global and regional left ventricular function

• At the mvocardial level, : diagnose infarction and assess viability.

• Coronary artery : stenoses can be localized and their severity quantified
• mvocardial pertusion
Novel application of microbubble
• Quantification: active or passive
• Passive: passage of microbubble recorded along with microbubble
disruption
• Active: microbubble is deliberately disrupted so replenishment of
tissue bed is measured. PHASE INVERSION MODE

• Microbubble conc: linearly depend on doppler signal intensity.

• a bolus injection of microbubble:
a tumor to generate transit time curve
bolus arrival time, time to peak intensity, area under the curve,
wash in/ wash out characteristics as well as more complex
deconvolution indices.
• hepatic vascular transit times:
while interrogating a hepatic vein with spectral Doppler.
Early arrival of contrast medium : in cirrhosis and malignancy because of
an increased hepatic arterial supply and arteriovenous shunting.
highly sensitive indicator of cirrhosis and metastases
for the presence of micrometastasis
• Active quantitation : destruction of microbubbles and observing the effects on
contrast enhancement ('reperfusion kinetics").

• Intermittent high power ultrasound pulses : destroy microbubbles within the

beam and the rate of replenishment in the field used to calculate indices such as
microcirculatory flow rate, a measure of tissue perfusion.
tissue-specific phase :
imaged by bubble-specific modes such as loss
of correlation (LOC) and phase inversion
Phase/Pulse Inversion Mode (PIM).
PIM detects non-linear echoes from
microbubbles

CLINICAL RADIOLOGY
Echoes from linear and non-linear sources can be
separated
non-linear signals, such as those from microbubbles,
summate while linear signals cancel.
Liver-specific Microbubbles
• Microbubble are solely blood pool agents.
• Some agenet likle Levovist, Sonavist, Sonazoid and BRI4
shows hepatosplenic-specific parenchymal phase following Liver malignancies appear as defects
disappearance from the blood pool. surrounded by an intensely bright
• hepatic accumulation is unknown but may be within the parenchyma in the late phase of
reticulo-endothelial system, or pool in sinusoids. Levovist(LP-PIM)
• variable duration lasting under about 30 minutes with Levovist
but longer with other agents such as Sonazoid and Sonavist.
• imaged by bubble-specific modes such as loss of correlation
(LOC)
and phase inversion mode(PIM)
phase inversion mode(PIM)

Liver malignancies: defects surrounded by an

intensely bright parenchyma in the late phase of
Levovist(LP-PIM)
Contrast agents : detection of hepatocellular
carcinoma and differentiating regenerating nodules
and to detect recurrence in treated lesions
• Disadvantage:
effect is transient and the cine loop is
needed to revie.

local lesions such as haemangiomas which

exhibit peripheral globular enhancement and
centripetal filling-in analogous to that seen on CT
 Pretreatment gray-scale US
image shows a hypoechoic Pretreatment CEUS
nodule APHE

9 months after MWA

similar pretreatment CEUS 9 months after MWA

gray-scale image ecompletely avascular:successful
ablation
 recurrence after RFA

CEUS
nodular APHE (arrows),
avascular treatment
site (arrowhead

(a) Gray-scale US image obtained 9 months

after treatment shows a heterogeneous
treatment site (arrowhead) and a vague
nodule (arrows) juxtaposed to the
treatment site border

definite weak washout

(arrows) of the recurrent
tumor adjacent to the
treatment site
(arrowhead).
Loss of Correlation Mode and Applications

• microbubble disruption : seen as a transient strong signal in colour or power Doppler.

• Microbubble disruption: sudden disappearance of a reflector : strong transient
signals on Doppler.
• In LOC mode :
 malignant liver tumours/ metastasis : defects surrounded by a colour mosaic pattern,
no or low LOC signals
 hamangiomas and local nodular hyperplasia (FNH): significantly higher scores.

• Disadvantage:
transient nature means so cine loop required.
effect falls of at depths greater than 10-12 cm
 SUPERRESOLUTION ULTRASOUND IMAGING

• superresolution to analyze microvasculature of tissues.

• by tracking the path of microbubbles in vivo and by
plotting their centroid positions and tracking their
movement over time
• postprocessing algorithm enabled the extraction of flow
direction and velocity information from the
microvasculature
• visualize vessels as small as 19 um—a much higher
resolution than is achievable with clinical Doppler
imaging
• record 500 frames/s
• Such a high frame rate, and scanning times of up to 10
min, ultrasound imaging is striving for superresolution
to analyze the microvasculature of tissues.
 INTERVENTIONAL US AND THERAPY
• High Intensity Focused Ultrasound (HIFU):
intensity of greater than 5 W/cm:
• (100 to 10,000 W/cm2) Frictional :heat coagulation necrosis

• therapies such as tissue ablation, image-guided

drug delivery, sensitization to radiation therapy,
and immune stimulation. a. Cigar-shaped thermal lesion is formed
at focal zone of US wave pathway (two
• to destroy a defined volume of tissue by inducing overlaid triangles) following HIFU single
a rapid rise in temperature to greater than 50 C exposure
for 1 - 3 s results in cell death, a single US b. Final thermal lesion after stacking each
exposure destroying 0.5 ml volume of tissue. single lesion.
• to treat malignant tumours of the liver, prostate
and kidney, pain in bone metastases.
•.
• Limitation: small volume, the inability to treat
through bone, and difficulty in monitoring
therapy in real-time.
• Since B-mode US does not distinguish
between coagulated and normal tissue,
alternate ultrasonic imaging methods such
as elastography, reflex transmission imaging
and thermal imaging

• Future applications:
• induce hyperthermia, an excellent
radiosensitizer studies ongoing to use
HIFU in radiotherapy
• re-vascularization of the myocardium by the
creation of channels in the ventricular wall
• the emergency treatment of internal
haemorrhage by inducing haemostasis
 MOLECULAR ULTRASOUND IMAGING
• targeted microbubbles to investigate molecular
alterations of the endothelium
• tumor angiogenesis and treatment response:
 microbubbles targeting the vascular endothelial growth factor
receptor 2 (VEGFR2) :
 VEGFR2 expression in the malignant breast and ovarian
tumors
• Inflammation:
 in cardiovascular and gastrointestinal diseases,
mainly microbubbles targeting P-selectin, E-
selectin, intercellular adhesion molecule 1, and
vascular adhesion molecule 1 (VCAM-1)
BR55 ligand for VEGFR2
detecting acute colitis and acute phases of tumor angiogenesis
chronic inflammatory bowel disease
 Ultrasound Drug and Gene Delivery
• Enhance the effect of thrombolytic agent:
• by adding microbubbles: delivery into thrombus (incorporating ligands on the
surface of the microbubble that binds GPIIB/IIIA receptors on activated
platelets.)
• further enhances thrombolytic activity by aiding penetration into the thrombus .
• triple combination of tPA, ultrasound high frequency, and microbubbles )
 sonoporation

• transient increase in cell membrane permeability.

• cellular uptake of a drug (e.g. a chemotherapeutic agent) or a gene.
• direct drug delivery (i.e., drug entrapment within the microbubble core or shell) or
to indirect drug delivery (i.e., coadministration of drugs and microbubbles,
• requires high acoustic powers
• A drug or gene vector
• incorporated in or on the surface of the
microbubbles
• and tracked in the circulation
• vicinity of the target tissue : exposed to
high power US,
• the advantage:
• decreasing the dose of the drug
needed.
• so reducing systemic side-effects.
• transfection of a reporter gene in a mouse
heart model increased 10-fold using a
microbubble carrying an adenovirus gene
vector.
 Interventional Procedures

• dedicated interventional transducers (i.e. intraoperative,

laparoscopic, transrectal), for intravenous access, etc.)
which have broadened the fields of application.
• Future endoscopic and laparoscopic US transducers :
built-in biopsy channels allowing both diagnostic
biopsies and therapeutic applications (e.g. cryo-, RF-
electrocautery. HIFU, microwave devices). fiber optic hydrophone (FOH) ultrasound
receiver, positioned within the lumen of a
• transducers equipped with biopsy guiding facilities and 20G needle, receives transmissions from
needle tracking systems to enhance needle visualization the side arrays
• 3D US may provide image information allowing multi-
planar planning and execution of interventional
procedures.
 RADIOMIC ULTRASOUND ANALYSIS
• High-throughput screening and
advanced pattern-recognition
algorithms to identify diagnostically
relevant imaging biomarkers and
their ideal combinations
• Although radiomic studies are
emerging for CT and MRI data,
• Hardly for USG due to difficulties in
standardizing data acquisition and
quantitative data extraction
• ultrasound data can also be used for
radiomic analysis in future.
• SUMMARY
impressive metamorphosis since its beginnings and now occupies a
pivotal role at the forefront of radiological practice and research.
• due to technological advances in electronics and computing and is
responsible for the diversity of imaging modes at the sonographer's
disposal.
• Microbubble contrast agents have dramatical extended the clinical
and research applications of ultra-sound.
• to encompass therapeutic options.
• its potential is boundless.
• Which type of modification in USG imaging ?

a)Photopic Ultrasound Imaging

B)photoacoustic imaging
 • Photopic Ultrasound Imaging:

• to optimize grey-scale tissue differentiation.

• improves image contrast
• and may be particularly useful in musculoskeletal applications.
• What is advantage of shear wave elastography over strain
elastography?
• a) use mechanical compression to produce shear wave.
• b) can quantify the stiffness of tissue.
• C) can be use in both focal and diffuse pathology
• D) both b and c.
 • both b and c.
strain shear

availability wide limited

Quality image excellent good

Depth Good Limited 6cm

Quantification limited excellent

Diffuse/focal focal Focal/diffuse

References:
1. Advances in ultrasound, Christopher J Harvey, et al
2. Update to the Society of Radiologists in Ultrasound Liver
Elastography Consensus Statement, Richard G Barr et al, 202, RSN
3. Diagnostic Ultrasound , 5th edition, Carol M. Rumack
4. B-mode US: Basic Concepts and NewTechnology, RSNA Physics
Tutorial for Residents