JDMS 21:1735 January/February 2005

17

ARTICLE 10.1177/8756479304272711 JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY January/February 2005 WHY WE DO THE THINGS WE DO (IN ULTRASOUND) / Milburn JDMS 21:1735 JDMS 21:1735 January/February 2005 January/February 2005 VOL. 21, NO. 1

An Overview:

Why We Do the Things We Do (in Ultrasound)

DONALD T. MILBURN, RDCS, RVT

Why does every ultrasound textbook begin with a physics chapter? Dont you know everything you need to know about ultrasound physics? After all, youve probably been performing echocardiograms or sonograms for years. How will learning more about the physical principles of sound make you a better sonographer? This article will answer these questions in order. You simply cannot be the best if you dont know the physics of sound. Key words: ultrasound, physics, instrumentation, Doppler

Lets Answer These Questions in Order

In accordance with ACCME Standards, authors are required to disclose any commercial affiliations or financial interests that might be perceived as a real or apparent conflict of interest related to the content of their JDMS CME article. The author, Donald Milburn, RDCS, RVT, is an employee of GE UltrasoundEducation.

Correspondence: Dawn Sanchez, Society for Diagnostic Medical Sonography, 2745 N. Dallas Parkway, Suite 350, Plano, TX 75093; email: dsanchez@sdms.org. Article originally published by the SDMS Educational Foundation within the Integrated Ultrasound Reference Guide, Volume 2. JDMS expresses appreciation to Michelle Bierig, MPH, RDMS, RDCS, for editing and updates. DOI: 10.1177/8756479304272711

Every text begins with physics because everything we do in ultrasound is based on our understanding of how to control this thing called ultrasound. From the beginning to the end of every sonogram, the best sonographers are the ones that not only perform that exam but also understand the nature of sound and how to control it for optimal results. You simply cannot be the best if you dont know the physics of sound. For those of you who have been doing these exams for years and think you know enough physics, are you really being truthful? The manufacturers who design and produce these marvelous systems we work with are constantly pushing the known limits of our technologies. Look around at some of the newer systems. Most offer new capabilities, which let the operator work with different transmit and receive image frequencies and multiple Doppler frequencies all within one probe. Do you know why? How can this remarkable ability help you in your day-to-day life in the lab? Do you really know why there are so many probe types and frequencies available? Do you know the advantages and disad-

18

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY January/February 2005 VOL. 21, NO. 1

FIG. 1.

FIG. 2.

vantages of all of them? Did you know that each type has certain performance levels and limitations? Why one probe does excellent color Doppler and is more sensitive to detecting slow flow while the other will make clearer 2D near fields and overall better images? If you dont know, then you need ultrasound physics. Finally, the answer to the third question is easy. The more you know about acoustic physics, the more you will understand ultrasound technology. When you can truly control that technology, the better sonographer you become. You graduate from the level of button pushing and rote memory

to being truly competent, highly sought after, and fabulously wealthy. Disclaimer: Be advisedif you are looking for a formal physics chapter, this is not it. There are plenty of those out there; however, if you want a commonsense practical explanation of how ultrasound works, then this is the chapter for you.

Where Do We Begin?
What is sound? Sound waves are mechanically produced longitudinal waves or vibrations that like to travel in straight lines. Just as the audible sound

WHY WE DO THE THINGS WE DO (IN ULTRASOUND) / Milburn

19

we hear every day reacts to certain laws, ultrasound is held to similar laws and constraints. In audible sound (20-20,000 hertz), we can hear the sound from voices or noises reflecting from distant objects. We also know that audible sound has difficulty passing or traveling through certain substances and will be attenuated or not heard at all. We know that different ranges or frequencies of sound affect us differently. The booming bass generated by a neighbors stereo seems to penetrate all the walls in your house. The high frequencies of the lead sopranos voice is piercing to the front-row listener but hardly audible to the rear of the performance hall. We live every day with sound and accept what we hear. In ultrasound, our sound cannot travel through air; it can only exist and travel in a media, which, in our case, is the tissues and blood of our bodies.

chines and no one-button patients, a control that is not used potentially limits acoustic data by restricting proper manipulation of the sound.

GainThe Most Basic of Controls

There are several types of gain found on the ultrasound system: power/transmit gain, master/ receive gain, depth/time gain compensation, and lateral gain compensation. All systems have controls regulating how much power is sent into the body (transmit gain). You must remember that transmit gain regulates how much power the patient is being insonated with. The Food and Drug Administration (FDA) regulates this gain by exam and transducer type. Most modern systems use icons or presets that will not let you use more power than is allowed for that type of exam; however, power levels can be exceeded by using incorrect configurations. (Example: using an adult cardiac probe and preset to perform a fetal exam.) It is the responsibility of the operator to ensure that proper probe types and power levels are utilized. Master gain or receive gain simply amplifies the returning signal or the received data, much like turning up the volume of your stereo. Another type of gain is depth/time gain compensation (DGC/TGC). This gain lets us configure our gain for depth by compensating for attenuation or the loss of power throughout the field of view (FOV). DGC lets us amplify far-field echoes and minimize near- and mid-field echoes so a balanced 2D display is received. DGC is like master or receive gain in that it is received data that are being manipulated, not transmitted gain. You are only adjusting the received sound. For a more thorough explanation of system controls, refer to the glossary of controls at the end of this article. Lateral gain compensation (LGC) is similar to DGC/TGC but changes the gain across the field of view. This allows the sonographer to compensate for lateral loss of power.

How Do We Produce Ultrasound?

Transducers or crystals produce ultrasound. Electronic stimulation of these crystals causes an expansion and contraction (Piezoelectric effect) of the crystal material, which subsequently produces a mechanical wave of energy we call ultrasound. From this point on, everything you do in your sonogram relates to controlling how much sound goes into the body and how we shape, focus, and configure the sound that is transmitted and received. All of this is accomplished through proper transducer selection (type and frequency) and the correct utilization of your system controls. Remember that manufacturers do not put lots of knobs, buttons, and dials on a system to improve its looks. They are there for you to control and improve the acoustic data you are transmitting and receiving.

This Thing Will Not Explode?

Many, many times over my career as an instructor, I have heard the comments, We never touch that control, or My boss told me to never flip that switch, or, my favorite, We taped that one down so we could not adjust it. You simply cannot hurt an ultrasound system by manipulating its controls; you only improve or worsen the transmitted and received data. Since there are no one-button ma-

Taming the Beast

Your life will be made infinitely easier by using the manufacturers specified icons, presets, and exam-type settings. These automatically select the

20

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY January/February 2005 VOL. 21, NO. 1

FIG. 3.

FIG. 4.

FDA recommended power settings for 2D, Mmode, and Doppler and allow you to set up your system quickly and efficiently. This does not mean you dont have to learn the system controls because their purpose is to fine-tune the presets. Finally, dont be afraid to ask for help if you dont understand all of the controls on your system. Requesting help lets your coworkers know that you are a true professional and lets you know how much they dont know either.

puters and beam forming technologies to provide us with the beautiful pictures we are used to seeing; however, not everyone uses the same probes. In fact, there are very few transducer manufacturers, and most systems use crystals made by someone else for the production of their probes. Specific information on how transducers are manufactured is proprietary.

ProbesThat Old Black Magic

Probes really are the heart and soul of a system. Most manufacturers use basically the same com-

So Whats Up With All These Different Probe Types?

Cardiac sonographers are used to using phasedarray probes for echocardiograms. However, most sonographers cross over into different specialty

WHY WE DO THE THINGS WE DO (IN ULTRASOUND) / Milburn

21

areas, and we are used to seeing linear-array probes as well. In fact, it is becoming quite common for shared service systems to utilize all probe types: phased, flat linear, curved linear, etc. So why do we have all of them? A basic fact we must learn is that an ultrasound exam is a series of trade-offs or compromises. For every advantage a certain technology has, there will also be a disadvantage. These differences directly affect the quality and ease of acquisition of our ultrasound data. We all know from our years of intense study of ultrasound physics that a high frequency will provide better spatial resolution with decreased penetration, while a lower frequency penetrates large patients, but the spatial resolution leaves something to be desired. This is all based on sound wave intervals and other conversation-starting words like period, wavelength, and cycles per second. The modern lab of today requires that we select probes not only on frequency but also for bandwidth, footprint, image quality, and Doppler performance. Modern probes also employ broad bandwidths, which means that there are multiple frequencies available for image and Doppler acquisition within each probe. The listed frequency on the probe is the center frequency. As Figure 4 shows, different transmit and receive frequencies may be selected to optimize image quality and penetration and Doppler penetration, sensitivity, and aliasing limits. Our final types of transducer arrays are linear and curved-linear or switched-array probes. While phased and linear probes are both electronic, linear probes generate their sectors differently from phased arrays. Linear and curved-linear probes are typically larger than phased arrays and are ideally suited for vascular examinations (flat linear) and abdominal, OB/GYN studies (curved linear). Their larger probe face, shape, and overall footprint provide much bigger and better near fields than phased arrays but limit their use in cardiology. Newer transducers also have bandwidths capable of providing harmonics, which enables enhanced imaging capabilities. A harmonic image is created by sending a frequency into tissue (lets say 2 MHz or f 1) and listening to the multiple of that frequency (in this case, 4 MHz or f 2). When ultrasound propagates through tissue, the inherent resistance, along with the time and distance traveled,

produces multiple frequencies in the positive and subharmonic ranges. Signal-processing techniques allow the operator to utilize the 2nd harmonic or the doubled fundamental frequency to our advantage. Harmonic imaging allows us to have the benefit of low-frequency imaging for penetration while displaying the high-frequency multiple, which provides optimal spatial resolution. Harmonics are also being used in conjunction with ultrasound contrast agents in the positive and subharmonic frequency ranges to elicit increased activity and reflectivity in differing agents. Okay, now you know a little about sound, its basic controls, frequencies, and probes, so whats next?

Christian Doppler: Did He Know Anything About Blood Flow?

I dont think Mr. Doppler knew anything about the detection of moving blood cells or the potential revenue generated by speeding tickets, but his legacy is alive and well in both ultrasound labs and police departments. Mr. Doppler was in reality trying to figure out why stars twinkle (or give off colored light shifts, depending on the relative motion between themselves and the stationary observers . . . us). For fun, look up his original paper On the Theory of Coloured Lights of Stars, written in 1842. His genius will amaze you and give you a whole new outlook on the science of Doppler. His observations stated that if a target is in motion and emitting a light source, then the distance between the source and the person or thing observing that motion will increase or decrease. This difference is the frequency shift generated by the shortening or lengthening of the signal intervals based on distance. (Say that five times quickly.) To us as sonographers, it means that if we transmit a frequency (your choice) from a stationary object (the probe) to a moving target (blood cells), the distance between the blood cells and the probe will either lengthen or shorten depending on the directional movement of the blood. The speed at which this happens is called a frequency shift. The frequency shift is expressed in kilohertz (kHz), converted to velocity (cm/sec) and displayed. The equation, which expresses Doppler acquisition, is as follows:

22

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY January/February 2005 VOL. 21, NO. 1

FIG. 5.

FIG. 6.

WHY WE DO THE THINGS WE DO (IN ULTRASOUND) / Milburn

23

FIG. 7.

pf =

2 foV (cos), c

where f = the detected Doppler frequency shift, fo = fundamental Doppler frequency, V = velocity of the moving blood, c = speed of sound in tissue, and = the angle between the ultrasound beam and the flow direction.

Im Not a Mathematician, So Do I Need to Know That Equation?

The answer is YES. You simply cannot be a Dopplerist without understanding the Doppler equation. It relates to and explains everything we do in Doppler. Let me explain. Delta f is the detected frequency shift or the difference between what was transmitted into the body in MHz and what was received in kHz. Lets say, for example, that you used a 6.0-MHz Doppler transmit frequency and the received signal was 4.0 kHz in the positive direction. This means 6 million cycles per second were transmitted into the bloodstream, and what returned was 6 million plus 4.0 kHz. If the blood were moving away from the transducer, the signal would be read as 6 million minus 4 kHz, and the display would be in the negative direction. Now we can see that the frequency shift delta f is always going to be the product of the equation and will be affected if we change any of the parameters in that equation. Now lets look at those remaining parameters: 2, fo, V, c, cos.

2This indicates that the sound must travel into the body and return to the probe. Since this always has to happen for Doppler detection, this parameter becomes a constant. foThe Doppler frequency that you are using. If this changes, the frequency shift will change. VVelocity of the blood. This will change, and the change is reflected in the frequency shift. cThe speed of sound in tissue. Again, a constant. cosineThe cosine of the angle between the insonation beam and the blood flow. One can now see why you need to understand the relationship of these parameters. Any change in them directly affects the frequency shift. Now you know why proper Doppler frequency selection and angle are so important. The higher the Doppler frequency, the higher the returned frequency shift. The closer to 0 degrees your angle becomes, the higher the frequency shift becomes. To the novice, this becomes confusing but is easily explained. Doppler is an angles game. The best angle for Doppler is 0 degrees. However, this is difficult (and very painful) to obtain on noncardiac studies. We must therefore rely on varying insonation angles to transmit and receive an adequate frequency shift. We have all heard that the worst angle for Doppler detection is 90 degrees, and Figure 8 shows why.

24

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY January/February 2005 VOL. 21, NO. 1

FIG. 8.

Okay, I Believe in Angles but What Angles Do I Use?

We now have two different sets of rules to live by. In the vascular and abdominal Doppler world, the Intersocietal Commission for the Accreditation of Vascular Labs (ICAVL) states: Doppler angles of 60 degrees or less must be maintained. By proper use of angles within this range, the errors associated in estimating frequencies and velocities are minimized. The closer to 90 degrees the angle becomes, the higher the error rates and associated spectral broadening artifact. Incorrect angles can cause over/underestimation of signals and introduce artifactual spectral noise. Sixty degrees or less has been proven to have an acceptable error range for vascular and abdominal Doppler. Cardiac Doppler is another story, however, and angle correction should not be used (0 degrees to the Doppler cursor).

difficult to reproduce patient to patient because as our Doppler equation demonstrated, if you change Doppler probe frequencies or angles, the frequency shift changes as well. In modern labs with multiple Doppler probes, frequencies, and operators, you can see how this becomes difficult to work with. It essentially means that you must have a separate diagnostic reference chart for every Doppler frequency that you use and for different angles as well. It can be done, but who needs the grief?

So Whats the Real Deal?

All of the previously mentioned problems exist when we live in the frequency world. To eliminate these problems, we simply convert our frequency shifts to velocities. This is done by inputting the flow angle. The sonographer selects the proper angle, that angle (cosine) is then displayed, and conversion to velocity is accomplished. With proper probe angulation and accurate angle correction, reproducible velocity conversions are obtained. One can now utilize multiple Doppler probe frequencies at multiple angles, and as long as the cosine is <60 degrees (0 degrees cardiac), the velocities will be valid. The frequency shifts will still differ, but velocities will be valid and reproducible patient to patient, lab to lab, system to system.

So Is All of This Just Related to the Doppler Cursor Angle?

Yes and no. The insonation angle of the Doppler cursor is but one part of the answer. By using only the displayed Doppler cursor, you only know the insonation angle, and that is all you need for frequency detection. However, frequencies are very

WHY WE DO THE THINGS WE DO (IN ULTRASOUND) / Milburn

25

FIG. 9.

Pulsed, High PRF and CW Doppler: Gimmicks or Real Tools?

Different types of Doppler exist because not any one type can provide all of the information on blood flow that we require. Sometimes we need accurate range location so we know precisely where a problem exists. This is when pulsed and high PRF Doppler comes into play. By targeting a specific site with your sample volume (location) and pulsing your Doppler frequency at certain speeds (pulse repetition frequency), we can, through time and distance calculations, accurately assess blood flow at specific sites. More simply stated, the system knows the distance from the crystal to the sample volume and how long it will take for the pulses of Doppler signals to get there. When that elapsed time has passed, Doppler receivers activate, and the blood signals at that point in time are collected. How fast we sample that point in time is how we can accurately assess the speed of the blood. Our sampling time is called pulse repetition frequency

(PRF), or sometimes it is referred to as scale. Highspeed flows require high sampling rates (PRF) for accurate, unaliased detection, and slow-moving blood requires low PRF for maximum sensitivity to slow flow.

That Sounds Great, but Doesnt There Have to Be a Downside?

Of course there has to be a downside. If the speed of the blood is faster than one half of the PRF, a pulsed Doppler system will alias, or the signal will wrap around the spectral display. This aliasing point is called the Nyquist limit.

One More Time

Example: If our PRF is 6 kHz, the Nyquist or aliasing point is 3 kHz. A detected blood signal >3 kHz will be clipped off and seen to be coming from the opposite side of the scale. Aliasing is an artifact that occurs in all aspects of life, and we have all

26

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY January/February 2005 VOL. 21, NO. 1

FIG. 10.

FIG. 11.

seen examples. The forward-moving stagecoach wheel on TV that appears to be turning backwards or an airplane propeller that is rotating one direction but appears to be moving slowly in another are examples of aliasing. Since PRF affects our detection speed, then it would make sense to just in-

crease the PRF to eliminate aliasing. This is why we select high-PRF Doppler, which, through some electronic trickery, utilizes multiple sample volumes along the Doppler cursor. This allows the system to transmit a higher level of PRF to the sample volumes than allowed with single-gate pulsed

WHY WE DO THE THINGS WE DO (IN ULTRASOUND) / Milburn

27

FIG. 12.

Doppler. This works to a point, but even with high PRF selected, some flows, especially cardiac flows, will exceed pulsed Doppler capabilities, and then we employ another tool, continuous-wave Doppler (CW). CW Doppler essentially uses a split crystal or two sets of crystals to continuously transmit and receive Doppler data. Continuous-wave Doppler does not operate with PRF constraints, which provides us the ability to detect and display extremely high velocities without aliasing. The compromise, though (and there always is one), is that we sacrifice range location. Our sample volume in a CW probe is where the two beams intersect and can be quite long depending on probe frequency and configuration. This lack of a precise sample volume limits accurate range location. This does not present a large problem in cardiology but can present confusing spectral signals in the presence of multiple, closely spaced arteries and veins, which will all be detected simultaneously in a CW sample volume.

So Which One Do I Use and When?

This is one of those rare moments in life where the answer is easy and I have one that works. Accurate range location requires the use of pulsed or HPRF Doppler. As long as the PRF is capable of displaying the data you want in an unaliased form, this is the way to go. PW plus HPRF Doppler provides accurate range location and excellent spectral Doppler quality. So to provide velocity information at a specific location, pulsed Doppler should be used. The downside, Nyquist limits. Continuouswave Doppler provides limited range location with good spectral Doppler quality and no Nyquist limits. Continuous wave should be used when assessing peak velocity information. Both are invaluable tools, and a full-service Doppler laboratory needs both.

Color My World
The biggest problem with understanding color Doppler is eliminating all of the myths that exist concerning color Doppler. The most common are:

28

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY January/February 2005 VOL. 21, NO. 1

FIG. 13.

Color Doppler results are the same from all types of systems. Color Doppler provides quantitative velocity data. Color Doppler provides a real-time accurate assessment of blood flow.

Why Are Systems Different?

In reality, color Doppler is not the same from all systems because not all systems process Doppler the same way. Different manufacturers use various algorithms to process data, and though the basic colors of red, blue, and green may look similar system to system, interpretively, they can be quite different. There are no industry standards for what frequency shift depicts what shade of blue or red. Add to this the fact that by changing Doppler transmit frequency or color maps and the color scheme will change as well, and you begin to see why different systems will provide different-looking data.

I Heard There Was Velocity Data in Color

You are not alone in that belief, but because of the way color data are processed, it is impossible to derive accurate velocity data from a color display. Let me explain.

Color Doppler is a pulsed Doppler technology, meaning that to know where to depict the blood, we must know range location. Just as pulsed spectral Doppler uses a sample volume for range location, color does the same but utilizes many sample volumes. In fact, there can be thousands of sample volumes being sampled on a color image. A single sample volume can be corrected for angle and the data converted to a velocity. This is the job that pulsed or CW spectral Doppler does for us. In color, however, since thousands of sample volumes are used throughout a large region of interest (ROI), they cannot be angle corrected. Add to this the processing method color Doppler uses (autocorrelation), and the problem compounds itself. Autocorrelation means that all data from all color sample volumes being utilized in the color region of interest are averaged together to produce a mean frequency estimate. So, multiple sample volumes, uncorrected for angle and averaged together, cannot provide a quantitative velocity. Pretty colors, yes. Quantitation, no. These facts combined with the slow frame rates inherent in color Doppler, all of the various system controls that may be used to increase or decrease sensitivity, and different color maps may limit accurate, real-time displays of flow.

WHY WE DO THE THINGS WE DO (IN ULTRASOUND) / Milburn

29

So What Is Color Good For and Why Should I Use It?

Its simple. Now that you know the limitations of color Doppler, the attributes are easy to see. Color provides qualitative data on three things:

The existence of blood flow: If its there, moving, and you have your system controls properly adjusted, you see it. Direction: If you can detect blood flow, then you can tell which direction its going. Spatial characteristics: Color will show, again all things being properly adjusted, the quality of flow and the spatial characteristics (i.e., complete filling of vessels, chambers, etc.).

FIG. 14.

Lets Review

It all adds up to this: Existence of flow, direction, and spatial characteristics of flow = a qualitative assessment of blood flow. Color Doppler also provides a rapid assessment of flow abnormalities and general location, so pulsed or CW spectral Doppler can be employed. Spectral Doppler provides a quantitative assessment of flow.

Im Beginning to See the Big Picture Now

Color helps me locate the flow abnormality (qualify), and spectral Doppler then allows me to measure the velocities (quantify). Youve got it. You can see why spectral Doppler and color Doppler are complementary technologies. We need them both, and neither one really stands on its own. I like to look at it as a check and balance system. Doppler and color show essentially the same things but in different-looking displays. This means that if I suspect a problem, both color and Doppler should give positive results. If all my data match my suspicions, Ive found the problem.

Spectral Doppler can be continuous wave or pulsed wave. CW Doppler detects high frequencies without aliasing but has limited range location. Pulsed Doppler has accurate range location but is a pulsing technique (PRF) and will alias if the speed of the blood exceeds 1/2 of the PRF (Nyquist limit). Both PW and CW Doppler use the Fast Fourier Transform (FFT) process to compute peak frequency data from a single sample volume. CW and PW Doppler frequency shifts can be corrected for angle and converted to velocities. Spectral Doppler data are quantitative data. Color Doppler is a pulsed Doppler technique. Color Doppler must use pulse repetition frequencies. Color Doppler uses the autocorrelation processing technique. Autocorrelation averages the frequency shifts from millions of blood cells moving through thousands of sample volumes. A color Doppler display shows average frequency data. Color Doppler data are qualitative data.

30

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY January/February 2005 VOL. 21, NO. 1

FIG. 15.

Doppler Displays
You should now understand that Doppler is color and color is Doppler. This becomes apparent when we look at the similarities in the data provided on our spectral and color Doppler displays. As Figure 15 demonstrates, all displays show the difference between positive and negative flows. The spectral Doppler graph describes flow that is either moving towards or away from the transducer. A positive spectral shift will be written above the zero baseline. A positive color shift is written above the zero color baseline as well. Negative Doppler and color shifts are simply written in the opposite direction. As the graph shows, there are different kinds of displays available that all provide the same type of data.

or reversed flow by encoding it blue. Do not ever accept a color display at face value. Arterial flow is not always red, and venous or reversed flow is not always blue. A sound knowledge of anatomy, physiology, and hemodynamics is the best way to avoid mistakes in Doppler diagnosis.

And Finally, Use the Power!!!! (Power Doppler!)

Our final type of blood-detecting technology is called power Doppler imaging (PDI). PDI is essentially the same Doppler signal that color Doppler uses but is processed differently on the return trip through the system electronics. Color Doppler is a display of the non-anglecorrected, average, or mean frequency shifted Doppler data that is returned from the insonated blood. It is displayed in varying shades of red and blue and is subject to all of the artifacts and limitations of pulsed Doppler technology. Power Doppler displays the power or amplitude of the returned signal. Now, at this point, the average readers eyes begin to glaze over, but just bear with me for a moment as it is really rather easy to understand. Think about this; every b-mode image

Caution
All Doppler units have spectral and color invert controls, which allow positive and negative shifts to be reversed on their displays. There are times when this is an advantage, such as making arteries appear red regardless of their direction of flow. The invert control can help call attention to venous flow

WHY WE DO THE THINGS WE DO (IN ULTRASOUND) / Milburn

31

you produce and look at displays amplitude. The strongest amplitudes are displayed as the brightest whites, and the weakest amplitudes are displayed as the darkest grays or blacks. Power Doppler simply analyzes the strength or amplitude of the insonated blood cells and displays those ranges in shades of gold or yellow or something close to that. The highest concentrations of blood cells are located in the center of blood vessels, so the power display is brightest there. There are less blood cells at the edges of the vessels, so the returned amplitude signals are smaller, thus the definition of vessel walls. Those signals are displayed in shades of darker colors. Since we are looking at amplitude, not frequency data, PDI is not subject to the common Doppler artifacts such as aliasing, angle of insonation, etc. PDI is not as dependent on angles as color, so the typical signal dropout at 90-degree interfaces is greatly reduced. And an added bonus is that PDI is more sensitive to extreme slow flow than color Doppler is! So, if you need to know the direction of blood flow, use color Doppler and live with the inherent artifacts. If you need extreme sensitivity to slow flow or need to visualize residual lumens better or just hate Doppler artifacts, use power Doppler. As I said way back at the beginning of this article, though, everything has a trade-off, and PDI is much more sensitive to motion artifact, so uncooperative patients will present a problem. Also, PDI does not display hemodynamics very well, so color should be used to evaluate the motion of blood.

PRESETS/ICON Function

Allows rapid optimization of image, Doppler, and color parameters for all clinical applications. Proper use of system icons saves time, reduces button pushing, and ensures diagnostic results.
Recommendations

Presets/icons do many useful things. Many ultrasound manufacturers provide presets as a place to start, but optimizing the presets to lab preferences will be helpful. Their use sets proper gains, powers, PRF, DGC curves, filters, etc. Most important, they provide the FDA-recommended power levels for each application. Different clinical situations require that you intervene with system controls to optimize parameters. Use the preset/icon setting as a stepping-off point and adjust controls accordingly to clinical needs. Dont worry about power settings as the proper preset/icon selection will not let you exceed power levels for that application.
Clinical Situations

A Glossary of Doppler/Color Doppler Controls, Functions, and Uses

Note: All ultrasound systems use basically the same controls, but not all of the controls are called the same thing on all ultrasound systems. Its not that manufacturers deliberately try to confuse you, but marketing people need something to do with the thesaurus they got in college. Patents, trademarks, and lawyers also figure into this situation. All controls listed here use generic but accurate names.

Improper use of preset/icons will yield inadequate results. For example, the leg vein preset/icon sets parameters for low-speed venous flow detection. Trying to perform cardiac studies with the leg vein preset/icon will result in sensitivity to slow, phasic flow but no aliasing control for high-speed cardiac flow. Using the renal icon for a carotid study would provide the wrong filters and PRF performance, so a carotid study would be inadequate. Let the preset/icons work for you, not against you. You will save time, avoid frustration, and obtain optimal clinical data.
MASTER OR RECEIVE GAIN: COLOR OR SPECTRAL DOPPLER Function

Increases or decreases the received signal only Does not control insonative energy into tissue

32

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY January/February 2005 VOL. 21, NO. 1

Recommendation

Dont rely on icon preset adjustments. Always adjust gain for optimal signal display. Sometimes it helps to increase gain until display becomes noisy and then reduce gain to an acceptable level. This ensures you have correct gain settings.
Clinical Situations

blood is faster than 1/2 PRF (Nyquist limit). Normal flow can alias. Scale set too low in color can cause tissue flash to overlie blood signals or show color outside of cardiac chambers.
HIGH-PASS FILTERS (HPF) Function

Not enough Doppler gain = reduced display of low flow. Too much image gain can minimize color display. Too much color gain causes color bleeding onto tissue.

PRF/SCALE Function

Blood signals are high frequency, low amplitude. Tissue signals are low frequency, high amplitude. Low-frequency tissue signals can mask low blood flow signals. Filters help to eliminate low-frequency signals from tissue, thereby increasing the display of slow blood flow.

Scale or PRF controls the sample time or look time that is required to process Doppler information.

Recommendation

Slow flow detection requires low PRF settings. High flow detection requires high PRF settings. PRF also controls aliasing.

Use filters to display low-flow signals and reduce tissue flash. Filters should be set independent of PRF if possible. Caution: Think of filters as electronic erasers. They eliminate all signals from frequency shifts lower than the filter number you select (i.e., a filter setting of 200 Hz will display no frequencies lower than 200 Hz).
Clinical Situations

Recommendation

Do not rely on preset/icon PRF settings. Scale must be adjusted for each patient and different clinical situations. Use the preset as a starting point only. Increase or decrease scale for high or low flows and to control aliasing.
Clinical Situations

Increased PRF may eliminate display of extremely slow flows. When you suspect total occlusion or small areas of reflux, scale must be set at lower levels. Remember, color alone cannot diagnose total occlusion. Only rare cardiac situations require changing color Doppler PRF. Scale set too low will cause Doppler aliasing. Remember: aliasing occurs if the speed of the

Filters set too high will erase slow flow in extremely stenotic lumens and valves. Filters set too high can erase bidirectional flow in dissected vessel lumens. Filters set too low will cause tissue flash to obliterate small vessels. Filters set too high will erase the diastolic component of the waveform and the color profile. Filters set too high will erase small reflux flows. Use caution when comparing Doppler results from different systems. If the filters are not the same, the diastolic or low-flow component of the waveforms and colors can be different.

WHY WE DO THE THINGS WE DO (IN ULTRASOUND) / Milburn

33

DOPPLER ANGLE/STEERING Function

To provide optimal angle of interrogation angles for accurate Doppler signal acquisition. Remember that interrogation angles closest to 0 degrees provide highest frequency shifts.
Recommendation

veins in the neck and extremities are somewhat straight. Using Doppler/color invert makes it fairly simple to maintain a red or blue display regardless of the angle of Doppler interrogation. This is not the case in abdominal or cardiac Doppler. In these studies, red conventionally indicates positive flow, and blue indicates negative flow.
REGION OF INTEREST SIZE Function

Spectral Doppler requires angles less than 60 degrees in vascular work and 0 degrees in cardiac for accurate conversion of frequency shifts to velocities. The closer your angles are to 0 degrees, the better the quality of the signal will be, and velocity conversion will be even more accurate. Color Doppler does not display velocity data; therefore, angle is not as critical. Most color mappers provide steering angles of 20 degrees left or right of center. This provides directional color (red/ blue). Vessels that lie closest to 0 degrees will display the highest shifts and can cause aliasing. Remember, if you need directional color, steer left or right. Maximum color sensitivity to extremely slow flow, however, is obtained at the 0-degree angle.
DOPPLER/COLOR INVERT Function

The color region of interest (ROI) is adjustable in the axial and lateral dimensions to facilitate sampling large and small organs, various lengths of vessels, and small areas such as stenotic heart valves.
Recommendation

A Doppler invert control simply reverses the direction of the Doppler display. This helps maintain an antegrade or retrograde display for exam continuity regardless of flow direction.
Recommendation

The color ROI should be kept as small as possible to maintain optimal system performance. Opening the ROI in the axial dimension adds hundreds and sometimes thousands of sample volumes for color processing. If these sample volumes are in tissue and not the vasculature being sampled, the system is made inefficient by having to service sample sites of no interest. Increasing the ROI in the lateral dimension has a direct result on system frame rate and therefore temporal resolution. The wider the ROI is opened, the slower the frame rate becomes. Conversely, the smaller the ROI, the faster the frame rate. For optimal system performance, keep the ROI as small as possible while sampling the necessary area of interest.
Clinical Situations

Tortuous vasculature will have flow that moves in one direction in the vessel but in many directions to the interrogating Doppler beam. Use the Doppler/ color invert control to maintain a unidirectional color or spectral display.
Clinical Situations

Vascular labs have adopted the practice of displaying arteries as red and veins as blue. This can be easily accomplished as the major arteries and

It can be advantageous to display long segments of vessels, entire organs such as the kidneys, or complete cardiac chambers. This makes for easy interpretations, but frame rate and temporal resolution can be severely compromised. When it is necessary to increase ROI width, try reducing the color quality setting. By reducing the number of times each color vector is sampled, frame rate will increase. When color quality is set at its lowest set-

34

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY January/February 2005 VOL. 21, NO. 1

ting and the ROI is at its smallest size, the system will be at its most efficient performance level.
COLOR QUALITY Function

Controls the dwell time or sampling time for color Doppler. Color quality is also known as packet size or length and ensemble length. It simply means how many times and for how long does the system sample each color vector for our three basic components of flow, direction, speed and variance, or turbulence.
Recommendation

These vessels contain moving blood that Doppler is detecting, but since they are not seen as black, the system does not write color in them. B-scan/ color priority overcomes this liability by reducing the priority of gray scale in the decision process of writing color data. By reducing the gray-scale priority, color will be written in areas that are detected by Doppler but not displayed in B-mode imaging.
Clinical Situations

Color quality is directly related to how good the color display is. The longer the dwell time, the prettier and more homogeneous the color display. A shorter dwell time results in a more pixilated color display with a more accurate display of hemodynamic changes. The sonographer must decide what the quality of the color display will be.
Clinical Situations

Incorrect B-scan/color priority settings will eliminate flow from tiny vessels that are not visualized. When performing color Doppler studies of the thyroid, testicles, fingers, tumors, etc., which typically have microvasculature, be certain that the priority is given to colornot B-scan.
COLOR MAPS Function

To provide different color schemes for the display of various hemodynamic conditions.
Recommendation

Color quality affects frame rates. The longer the dwell time, the prettier the color, but the slower the frame rate becomes. Reduced dwell times provide color images that may not be as aesthetically pleasing but will have faster frame rates and therefore better temporal resolution.
B-SCAN/COLOR PRIORITY Function

Everyone perceives color differently. Select the color map that presents the most frequency data (color) to your eyes. Icon or preset maps are usually best suited for their particular applications.
Clinical Situations

Allows color Doppler information to be displayed when vasculature is too small to be visualized in B-scan.
Recommendation

Red/blue maps provide directional indication. A rainbow map displays more colors than red and blue to match the various frequency shifts present. A rainbow map shows all flow present. The variance map should be used to indicate turbulent flow associated with luminal stenosis or valvular stenosis.
IMAGE/DOPPLER FREQUENCY CONFIGURE Function

A color mapper is designed to write color where it sees no gray-scale tissue data. This makes it easy for the system to write color on black vessels and not on tissue. There are many blood vessels in the body, however, that are smaller than the image resolution capabilities of ultrasound technology.

Provides multiple frequencies for 2D, spectral, and color Doppler imaging. These frequencies may all be different from the center frequency of the probe.

WHY WE DO THE THINGS WE DO (IN ULTRASOUND) / Milburn

35

Recommendations

100 sq. meters

Frequency configure is an extremely important control as it lets the sonographer optimize the proper frequency to the clinical situation. When it becomes advantageous to use higher transmit or receive frequencies for increased backscatter, greater sensitivity, improved spatial resolution, or lower frequencies to increase penetration and reduce aliasing, frequency configure should be used.
Clinical Situations

100 sq. decameters 100 sq. hectometers

Cubic Measure

= =

1 sq. decameter
1 sq. hectometer 1 sq. kilometer

1000 cu. millimeters 1000 cu. centimeters 1000 cu. decimeters

Linear Measure English 1 inch 1 foot Metric

= = =

1 cu. centimeter 1 cu. decimeter 1 cu. Meter

When using a 2.25-MHz transducer to image the heart, shifting image and Doppler frequencies can increase/decrease image resolution and Doppler sensitivity, increase/decrease Doppler backscatter, and improve color resolution. Backscatter can be increased for signal strength, small signals can be received at higher frequency shifts for easier detection, and resolution can be increased in both imaging and Doppler.

1 yard

1 mile

25.4 millimeters 2.54 centimeters 30.48 centimeters 3.048 decimeters 0.3048 meter 0.9144 meter 3.2808 feet 1.0936 1609.3 meters 1.6093 kilometers

0.3937 inch 3.937 inches

1 centimeter 1 decimeter

39.37 inches

1 meter

3280.8 feet 1093.6 yards 0.6137 mile 0.6138

1 kilometer

A Few More Interesting Things You Might Want to Know

The following charts list the most commonly used metric measurements. Since we use the metric system in medicine, you must be familiar with these values and terms.
CUSTOMARY/METRIC CONVERSIONS Linear Measurements

0.03937 inch 1 millimeter METRIC SYSTEMS Powers of Ten 10 6 10 3 10 2 10 1 10 1 10 2 10 3 10 6 10 9 10

9

Prefix giga mega kilo hecto deca deci centi milli micro nano

Symbol G M k h da d c m n

Meaning billion million thousand hundred ten tenth hundredth thousandth millionth billionth

10 millimeters 10 centimeters 10 decimeters 10 meters 10 decameters 10 hectometers

Square Measure

= = = = = =

1 centimeter 1 decimeter 1 meter 1 decameter 1 hectometer 1 kilometer

COMPLIMENTARY METRIC UNITS Numbers billions and billionths millions and millionths thousands and thousandths hundreds and hundredths tens and tenths Metric Equivalents giga & nano mega & micro kilo & milli hecto & centi deca & deci G&n M& k&m h&c da & d

100 sq. millimeters 100 sq. centimeters 100 sq. decimeters

= = =

1 sq. centimeter 1 sq. decimeter 1 sq. meter

36

JDMS 21:3637

January/February 2005

JDMS 21:3637 JDMS 21:3637

January/February 2005 January/February 2005

SDMS-JDMS CME TEST

Article: An Overview: Why We Do the Things We Do (in Ultrasound) Author: Donald T. Milburn, RDCS, RVT Category: Cardiac Physics and Instrumentation (CPI) Credit: 2.0 Objectives: After studying the article, An Overview: Why We Do the Things We Do (in Ultrasound), you will be able to 1. Describe optimal angles for Doppler tracings in cardiac and in abdominal and vascular examinations. 2. Describe the work of Christian Doppler. 3. Analyze the footprint associated with different types of transducers. 4. Associate types of gain to tissue and image effects. 5. Describe characteristics of color Doppler and continuous wave Doppler. 6. Convert metric values. 7. Define Nyquist limits that result in aliasing. 8. Describe the use of filters. 9. Specify synonyms for pulse repetition frequency. 1. In a cardiac sonography examination, the Doppler angle should be _____ degrees. a. zero b. 45 c. 60 or less d. 90 2. Which of the following probes typically has a small footprint? a. linear array b. curved linear array c. switched array d. phased array 3. Theoretical bioeffects of ultrasound are related to which of the following? a. transmit gain b. master gain c. depth/time gain compensation d. near field gain 4. Christian Doppler investigated which of the following? a. velocity of moving blood cells b. conversion of matter to energy c. light emitted from stars d. movements of bats 5. A signal will alias with pulsed Doppler when the speed of blood is faster than ____ the pulse repetition frequency. a. .05 times b. .5 times c. 1 times d. 1.5 times 6. Continuous wave spectral Doppler is useful for a. assessing peak velocity without aliasing b. providing velocity information at a specific location c. converting the signal to a color display d. determining the Nyquist limit 7. Filters set too low will a. erase small reflux flows b. erase slow flow in stenotic lumens c. erase bidirectional flow d. allow tissue flash to obliterate small vessels 8. Which of the following statements about color Doppler is false? Color Doppler a. is qualitative data b. is continuous wave Doppler c. displays average frequency data d. uses the autocorrelation processing technique 9. Pulse repetition frequency (PRF) is also known as a. velocity b. amplitude c. scale d. power 10. 254 millimeters is how many decimeters? a. 0.254 b. 2.54 c. 25.4 d. 254