Introduction To The Physical Principles of Ultrasound Imaging and Doppler Peter N Burns PHD
Introduction To The Physical Principles of Ultrasound Imaging and Doppler Peter N Burns PHD
Introduction To The Physical Principles of Ultrasound Imaging and Doppler Peter N Burns PHD
November 2005
Left: Real time ultrasound image of the four chambers of the heart, with colour Doppler showing regurgitation of
the mitral valve. Right: 3D Power Doppler image of the arterial circulation of the kidney.
Peter N Burns
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reception of the echo, the distance between the alternating voltage of the appropriate frequency
transducer and the echo-producing structure can be (say 3MHz) corresponding mechanical oscillations
calculated and an image formed (Figure 1). In and hence ultrasound waves (in this case
diagnostic imaging, frequencies vary from about consisting of 3 million compressions/second) are
2MHz for some cardiac, transcranial and deep produced. From the point of view of ultrasound
abdominal applications, through 10MHz for the imaging instrumentation, it is equally significant
imaging of superficial structures such as blood that the piezoelectric effect works in the opposite
vessels, to 20MHz or higher for intravascular sense, that is, varying mechanical pressure on the
imaging. At these frequencies, ultrasound has a face of the transducer will be converted into a
wavelength of between 1.5 and 0.08 mm, a corresponding variation in electrical potential
dimension which sets a fundamental limit on the across two faces. It is this voltage which results
potential spatial resolution of the resulting image. when the reflected portion of a pulse of ultrasound
Better resolution is associated with a higher findings its way back to the transducer and which
ultrasound frequency, but absorption of the sound is referred to as the echo signal.
energy by tissue also increases with frequency.
Optimum imaging is thus obtained by choosing Echoes arise when a burst of ultrasound (which
the highest frequency transducer which will permit travels through tissue at about 1500 metres/
adequate acoustic penetration to identify the
region of interest. To this end considerable effort medium 1 medium 2
has been expended to develop technologies which
will allow the transducer to be positioned nearer to
the structure of interest and hence achieve higher
resolution.
Sound
Sound consists of longitudinal vibrations which
propagate through a medium such as water or soft
tissue in much the same way as a compression can
be seen to travel along the length of a spring.
Sound consists of the repetitive (or periodic)
production of such compressions which travel in
regular succession. The number of compressions
produced each second is known as the frequency
(measured in Hertz, Hz, where 1MHz =
1,000,000Hz) and the distance between successive
compressions (which depends on the speed at
which the sound travels in the medium) is known
as the wavelength.
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second, or 3500 mph) encounters an interface such as this with echo amplitude on the vertical
between structures of differing acoustic axis and depth on the horizontal axis is known as
impedance. Acoustic impedance is a mechanical an A-mode scan (Figure 1).
property which for bulk tissue is defined as the
product of its density and the speed at which The echoes can also be displayed as dots in a
sound propagates through it. The speed of sound is straight line, with brightness proportional to echo
itself influenced by, amongst other factors, the amplitude (Figure 2c). If the transducer is then
stiffness of tissue. Thus ultrasound imaging is mounted on a position sensing arm, the line of
fundamentally a modality which maps the changes view of the acoustic beam can be made to
in a mechanical (rather than nuclear or atomic) correspond with the orientation of the brightness
property of tissue. As the scale over which these modulated A-scan line on the display screen.
mechanical properties affect ultrasound are Moving the arm across the skin's surface will then
comparable or greater than the wavelength of produce a series of dots corresponding to the
sound used, it turns out that many modifications to cross-section of the interface within tissue (Figure
the structure of tissue at the cellular level also 2e). Thus, an image of this interface is formed,
result in changes of its acoustic properties, known as a B-mode image. This cross-sectional
including acoustic impedance. Thus ultrasound is image forms the basis for almost all those of
an excellent method for the imaging of soft tissue modern ultrasound instruments. Figure 3 shows
structures. the major components of an ultrasound imaging
Ultrasound instrumentation system. The clock initiates the sequence which
If the difference in acoustic impedance between results in a single image being constructed on the
two structures is small (as it is in most soft tissue screen: A pulse is created by the pulse generator
interfaces), only a tiny proportion of the and emitted by the transducer. The direction in
ultrasound pulse will be reflected back toward the which the transducer is oriented is registered by
transducer; most of it will be transmitted and the coordinate computer, which feeds this
continue on to the next interface. Echoes arrive information to the scan converter. As the echoes
back at the transducer separated in time by a are received, they are amplified and demodulated
period proportional to the distance between to determine their strength. The stream of echoes
interfaces. The simplest (and in fact the most is then presented to the scan converter, which is a
accurate) way to measure this time is by memory capable of storing the echoes along with
displaying the echoes as deflections on a cathode their time of arrival and direction. These data are
ray tube. A spot is made to traverse the screen of then read from the memory in a television raster
the cathode ray tube rapidly from left to right and format and fed as a video signal to the imaging
the electrical signal from the transducer arranged monitor. As soon as all the echoes are received, the
to cause a vertical deflection. Thus in figure 1, the clock initiates another, identical sequence. As the
first deflection occurs as the electrical pulse is transducer is scanned over the patient, so an image
applied to the transducer. The acoustic pulse which is formed. If the scanning process is automated at
results from this travels into tissue until it a sufficiently rapid rate, enough images can be
encounters an interface which the acoustic produced every second for motion of tissue
impedance changes, from where the reflection structures to be followed in “real time”.
gives rise to an echo which travels back to the
transducer. When the echo reaches the transducer Variations in acoustic impedance may take the
an electrical signal is produced which causes a form of a smooth surface (such as the bladder
second deflection of the spot on the cathode ray wall), in which case the reflection of ultrasound
tube screen. If we assume sound to have traveled will be specular (Figure 4a) in analogy with light
at a steady speed in the tissue, the distance striking a glass interface. Echoes will only be seen
between the transducer and the interface can be if the beam is near perpendicular to the surface
measured from the distance between the two (Figure 4b). Older "bi-stable" ultrasound
deflections on the screen. A one-dimensional trace equipment was able to demonstrate only these
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Pulse
generator
Time-gain
compensation CLOCK
Medium 1 i r
Transmit/
Radiofrequency Demod- Video
z1
receive
amplifier ulator amplifier
switch
Medium 2
z
z2 t
x
Coordinate Image memory
computer (Scan converter)
y
a. Specular relection
Image Monitor
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thus allowing the diagnosis of abnormality. The
normal cortex of the kidney, for example, is
characterized by less intense parenchymal echoes
Medium 1 than that of the contiguous liver, spleen and
z1 pancreas. The parenchymal texture of these organs
is also different. In addition, specular echoes from
Medium 2 the renal sinus in the adult are more intense than
z2 t
those from within the cortex.
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screen capable of displaying no more than about respiration can identify it as arising from the
30dB, some compression of the range of echo peritoneal or retroperitoneal space. For example,
amplitudes is necessary. This is achieved by fluid-filled structures which pulsate may be
amplifying the low level echoes linearly, but the identified as arteries and ureteric jets may be
high level echoes in a manner which compresses visualized directly with real-time ultrasound as
them into a narrow dynamic range (Figure 6). This they empty into the bladder. Dynamic information
characteristic (known as the display compression may be recorded on videotape or "frozen" by an
or post-processing curve) may be adjusted to operator control and stored in an image memory.
enhance the contrast between a lesion and Review of a real-time ultrasound examination of
surrounding tissue of almost similar echo intensity. the abdomen can, however, be difficult as the
Thus, in Figure 6, the intensity ratio between hand-eye coordination of the scanning process is
echoes A and B, and between echoes C and D are impossible to record, and an appreciation of the
similar, but on the display the contrast between precise plane of visualization is often difficult to
echoes A and B is greater than that between echoes gather in retrospect. Multiple views in standard
C and D. Employing a different post-processing planes, however, although lending predictability to
characteristic, such as that of curve 1 in Figure 6, the images produced, result in the sacrifice of
will cause the display contrast to vary. In many many of the qualities unique to real-time
instruments, post-processing characteristics may ultrasound imaging.
be adjusted after the image has been acquired and
held in the scan-converter. Additional A variety of techniques may be used to move the
enhancement of edges may be provided by ultrasound beam in a real-time scanner. In the
electronic differentiation of the demodulated mechanical sector scanner (Figure 7a), the beam
signal, a processing facility built into many from a single transducer is moved by the rotation
modern abdominal scanners. In selecting post- of the ceramic element itself or of acoustic mirrors
processing characteristics, one should attempt to
optimize the contrast between structures of interest 3
D'
without sacrificing the dynamic range (that is, the C' 2
range of gray shades) in the display.
Display Brightness (dB)
B'
1
Real time ultrasound imaging
The process of moving a transducer attached to an A'
arm has been largely replaced in modern real-time
scanners by the movement of a transducer using a
mechanical rotator or translator, driven under
servo control such that the display of scan line is
moved in exact correspondence with the position
of the beam (Figure 7). The beam is swept with
sufficient speed that an entire image can be A B C D
produced in a fraction of a second, so that Echo Amplitude (dB)
independent images may be acquired at a rapid Figure 6 The compression amplification (or post-
rate. The display of these images in quick processing) curve demonstrates the relationship
succession and the elimination of flicker by between the echo amplitude returning to the transducer
switching between image memories, creates a and the display brightness. Note that there is a constant
device capable of visualizing structures which are difference in echo amplitude between echoes A and B
moving a real time. The assessment of the move and echoes C and D. With post processing curve 1 these
movement of tissue in the abdomen yields would result in an equal difference between the display
additional diagnostic information unique to brightness of these two sets of echoes. With the post
ultrasound imaging. Movement of a lesion during processing curve 3 however, the contrast between
echoes A and B is greater than the contrast between
echoes C and D.
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Mechanical Sector
Electronic Sector
Ultrasound
wavefront
Electronic Array
delays elements
Figure 8 The principle of the phased array. A similar
transmit pulse is fed to each of the array elements but
after a delay which increases progressively from one
end of the array to the other. The result is an ultrasound
wavefront whose direction of motion is at an angle to
the axis of the probe. Such "steering" of the ultrasound
beam can be achieved very rapidly by the phased array
system.
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other hand the linear array has proved to be ideal
for scanning areas with large windows and a
smooth abdominal surface such as the pregnant
uterus. The curvilinear array (Figure 7d) creates a
trapezoidal field of view with a somewhat smaller
acoustic footprint than the linear array, but shares
many of its advantages.
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delays
for the beam. This creates a desired focal depth for delays
array when receiving allows an electronic focus to Figure 11 The annular array. The annular array, like
be formed whose position sweeps downwards as the phased array, is capable of synthesizing a focus at
echoes arrive from progressively deeper structures. the desired distance from the transducer, whose axial
Use of electronically focused beams improves the location can then be swept during the reception of each
uniformity of image quality at different depths, train of echoes. The annular array, unlike the linear
especially enhancing visualization of structures phased array, focuses the ultrasound beam in two
near the transducer face. dimensions.
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radial scan, whose plane lies at right angles to that
of the probe. Figure 12b shows a mechanical
sector scanner whose plane contains the axis of
a.
the probe (an axial plane). In Figure 12c the 115°
b.
a.
c.
b.
d.
c.
Figure 12 Some configurations of mechanical real time
scanners used for transrectal scanning. a. The 360
degree radial scanner. b. The axial sector scanner. c. An
axial sector scanner with adjustable scan plane. d. A
mechanical sector scanner whose scan plane may be
adjusted between axial and radial planes.
d.
Ultrasound transducers, based on the mechanical Figure 13 Some configurations of electronic array
sector, the phased sector, linear and curvilinear scanners used for transrectal scanning. a. The
array, have been produced in a wide variety of axial phased array sector scanner. b. Axial linear
sizes and shapes. Transducers designed for array scanner with a rectangular field of view; c.
transrectal scanning have been built using linear Two phased array sector scanners, giving an axial and
array or rotating mechanical sector designs. These a radial orientation. d. A phased/linear array
are used routinely for prostate and bladder hybrid, the linear array providing the axial scan
imaging. Transurethral transducers are available plane.
for the examination of, for example, the walls of
the bladder. Finally, small electronically steered
sectors and high frequency linear array systems sector can be adjusted so that, while lying in an
have been designed for intra-operative use. axial plane, it can be oriented to face angles from
Transducers of all types are also available with forward to perpendicular to the probe. Figure 12d
attachments to guide a biopsy needle under shows a similar arrangement, but in which the
ultrasound imaging control. plane of the sector, while fixed at 90° to the probe
axis, can be rotated from an axial to a radial
Figure 12 shows a sample of intracvity probe direction. In all of these systems, the motor driving
configurations which employ mechanically the transducer motion is housed within the probe
translated ultrasound beams. In Figure 12a, a handle. Electronic arrays have the advantage for
single transducer rotates so as to produce a 360° intracavity imaging that they require no moving
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Transducer Transducer
parts, so can be made smaller, Also, linear or
curvilinear arrays offer a larger field of view
ity
which may make anatomic orientation of the
c
lo
Low velocity
ve
w
Refracted
operator less difficult. Figure 13a shows an axial
Lo
beam
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renal cortex and sinus, but can be significant
between fat and collagen. As the scanner assumes
ultrasound to travel in a straight line, and as the
echoes return along the same path as the
Medium 1 i r transmitted pulse, all structures distal to the
c1 refracting interface will be shown in the wrong
location, and their spatial relationship to nearby
Medium 2 structures which were imaged without refraction,
c2 t will be distorted (Figure 15b).
a. Short Pulse
Figure 16 Refraction. If the velocity of sound c is Image
Transducer
different between two media, and the beam is incident at
a non-perpendicular angle, the angle of transmission Short
pulse
will be different to the angle of incidence.
15a).
Figure 17 Axial resolution. The axial length of the
Finally, the assumption implicit in instrument
image of a point target depends on the length of the
design that the ultrasound travels in a straight line
pulse imaged from the ultrasound transducer. This
may be breached by the phenomenon of refraction
varies with transducer construction and size, as well as
(Figure 16). Among the factors which influences
frequency.
the acoustic impedance of a given tissue is the
velocity at which sound travels in it. Thus, an
interface between two tissues of differing velocity Images
will give rise to an echo by reflection. However, as In many instances, ultrasound is used to make
the transmitted portion of the pulse continues into anatomic measurements of an organ or a lesion.
the deeper tissue, its path is deviated at the Certain limitations to the precision of such
interface. The degree of deviation from a straight measurements are a fundamental consequence of
line depends on the difference in velocities across the physics of the image itself: no amount of care
the interface: this may be negligible between, say, on the part of the operator will alleviate these
Peter N Burns
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constraints. In particular, the resolution of the direction perpendicular to the ultrasound beam,
image determines the best precision of any which results in their being imaged as two distinct
measurement made from it. In ultrasound images, structures. Figure 18 shows that the principal
the resolution varies within each image, and determinant of lateral resolution is the width of the
between the three directions defined by the scan ultrasound beam. In general, the lateral resolution
plane. is inferior to, or at best comparable to, the axial
resolution. Highly focused beams, such as the one
Axial resolution shown here, achieve good lateral resolution in the
Axial resolution is defined as the minimum
separation of two targets in tissue in a direction
parallel to the beam which results in their being Direction of scan
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with increasing transducer frequency. Even if will be corrupted by randomly distributed signals
swept focusing is employed, the high bandwidth of that have the appearance of 'snow' but are in fact
the pulse emitted from the transducer and the artifactual consequences of a low signal-to-noise
tendency of tissue to absorb high ultrasound ratio. Second, the ultrasound beam does not have a
frequencies more rapidly results in a lowering of uniform sensitivity pattern: at greater sensitivities,
the center frequency of the pulse as it traverses the beam is effectively wider. If the gain is
tissue. The result is that there is always some increased enough to detect a weak echo, stronger
degradation of both axial and lateral resolution echoes from the same depth will be 'smeared' so as
with increasing depth. to reduce lateral resolution. Thus the contrast
resolution is affected by echo amplitude and tissue
Slice thickness attenuation. This provokes an inevitable conflict
The ultrasound instrument assumes that all echoes between raising the ultrasound frequency, which
arise from the central axis of the beam. In reality results in higher spatial resolution, and lowering it,
echoes are produced by the full cross-section of which improves signal amplitude and hence often
the beam. This leads to an inevitable uncertainty contrast resolution. The optimum frequency with
over the actual location from which an echo arises, which to carry out a specific measurement is thus
causing what may be described as a always a compromise.
"superimposition" effect. Echoes arising from
tissues located near the edge of the beam are
presented in the image as if they are located on the
central axis of the beam. Therefore, any given
point in the ultrasound image represents a
summation of changes in tissue construction
across a slice of tissue. When viewing the image,
the observer is “looking through” a slice whose
thickness is equivalent to the width of the beam
which produced the image. This 'slice-thickness' is
one source of the characteristic "fuzzy" edges of
imaged spherical structures. Since most of the
surfaces in the body are curved, the ultrasound
image superimposes echoes from these curving
surfaces, producing less well defined margins to
structures.
Contrast
The effective resolution with which a structure can
II: DOPPLER
be delineated, and thus measured, from an
ultrasound image is also affected by the strength of Introduction
the echo itself. Several factors are involved. First, The rapid expansion of the Doppler method in
even a strong echo may arise from tissue ultrasound diagnosis reflects the breadth of
sufficiently deep for attenuation to render it weak application that data from the noninvasive
by the time it returns to the transducer: it only examination of blood flow offers. This expansion
takes about 4mm of muscle, for example, to has been marked both by technical developments,
reduce a 2.5MHz echo to one-half of its amplitude. such as colour Doppler imaging, and new clinical
A weak echo requires more amplification from the applications, such as transcranial Doppler
receiver, but increasing the receiver gain also imaging. For the sonographer and ultrasound
increases noise. If the echo is comparable in diagnostician, however, it has also resulted in a
amplitude to the noise, it will be difficult or rather bewildering array of new instruments, some
impossible to detect it on the image, and edges employing techniques, such as time domain colour
imaging, which are unfamiliar to many.
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Sound waves, comprising a series of
Doppler methods are unique among clinical compressions, travel toward the receiver at a
techniques in ultrasound in that they have the steady speed determined by the medium. The
potential to offer information related to the frequency received is simply the number of these
function of an organ rather than its morphology. compressions detected per second by the receiver.
However, they have in common with all In the example in which both the source and
ultrasound techniques that the information is receiver are stationary (Figure 19a), this is
derived from the interaction of a beam of sound obviously equal to the frequency that is
with a volume of tissue and therefore represents a transmitted. If, however, the receiver moves
combination of these two influences. Much of the toward the source (Figure 19b), it will detect more
interpretation of Doppler signals in clinical compressions per second and so register a higher
practice entails the extraction of information about frequency. Conversely, if the receiver moves away
the underlying blood flow from confounding from the source, fewer compressions reach the
factors related to the Doppler technique. This transducer per second and a lower frequency is
process has been made progressively more detected (Figure 19c). A precisely analogous effect
straightforward with the refinement of instruments occurs if the source moves away from a stationary
for the acquisition and analysis of Doppler signals. receiver (Figure 20). The motion of the source
However, the mere fact that the data cannot be towards the receiver causes the distance between
presented as a conventional image can challenge compressions - the wavelength - being reduced.
the sonographer who relies on an intuitive The result is that more compressions reach the
interpretation of an ultrasound study. An receiver per second and a higher frequency is
appreciation of the physical principles of the detected (Figure 20b). In the case of the source
Doppler effect not only help extend such an moving away from the receiver (Figure 20c), the
intuition into blood flow studies, but is an essential wavelength is reduced so that a lower frequency is
prerequisite for the quantitative interpretation of detected. It is easy to see from figures 1 and 2 that
Doppler signals. the greater the speed of the relative motion
between source and receiver, the greater the
The Doppler Effect Doppler shift in frequency. To a first
When a wave is reflected from a moving target, approximation, the effect of a moving receiver is
the frequency of the wave received differs from equal to that of a moving source.
that which is transmitted. This difference in
frequency is known as the Doppler shift and In the case of ultrasound being scattered from
depends on, among other things, the speed at moving red blood cells, two successive Doppler
which the target is moving and whether the motion shifts are involved (Figure 21). First, the sound
is toward or away from the receiver. Examples of from the stationary transmitting transducer is
the Doppler effect abound. For example, a listener received by the moving red blood cells. Second,
perceives the pitch of a moving source of sound to the cells act as a moving source as they reradiate
change according to whether the source is the ultrasound back toward the transducer, which
approaching or receding; an astronomer can is now a stationary receiver. To a first
determine the speed of rotation of the sun by approximation, these two Doppler shifts are equal
measuring the difference in frequency (that is, and simply add to each other. They account for the
colour) of light between the advancing and factor 2 appearing in the Doppler equation,
receding edges; the frequency of radio waves fD = 2 f v cosθ / c
received from a moving aircraft is shifted due to This equation relates the Doppler shift frequency
the Doppler effect. The acoustical Doppler effect fD (measured in Hz) to the velocity of the moving
occurs whenever there is relative motion between
blood v (in m/s), the frequency of the ultrasound f
the source and the receiver of sound. Consider the
(in Hz), the velocity of sound c in the medium (in
case in which the source is stationary and the
m/s), and the cosine of the angle θ between the
receiver is moving toward the source (Figure 19).
direction of motion and the axis of the ultrasound
Peter N Burns
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Peter N Burns
16
Another important effect that the composition of backing, which has the effect of increasing the
blood has on the nature of the Doppler signal overall sensitivity of the system). A continuous
arises from the combination of many individual stream of echoes arrives at the receiving
scattered waves produced by the erythrocytes. As transducer, whose output is amplified and fed to
long as the erythrocytes are not too close together, the demodulator. The function of the demodulator
each behaves as though it were an independent is to compare the frequency of the received echoes
receiver and scatterer of the sound. The waves to that of the oscillator and to derive a signal
resulting from these interactions spread out from whose frequency is equal to their difference- this
their many sources much as ripples do from small is the Doppler shift signal. Stationary interfaces
stones falling onto the surface of a pond. As these give rise to echoes whose frequency is identical to
waves meet each other, they combine according to that of the oscillator: these are rejected by the
their phase at the point of interception with, for demodulator. Most demodulators employ a
example, two maxima combining to form a technique known as phase quadrature detection,
maximum, a maximum and a minimum combining which is capable of distinguishing between signals
to form zero, and so on. The resulting interference whose frequency is higher and those whose
pattern extends back to the receiving transducer frequency is lower than that of the transmitted
face and moves along with the moving blood. This signal, corresponding to Doppler shifts toward or
gives rise to fluctuations in the strength of the away from the transducer. Such a directional
Doppler signal both in space and with time, and demodulator produces two outputs that, after
accounts for the distinctive noise like character of filtering, have a phase relationship determined by
Doppler blood flow signals. It also allows a the direction of flow. Further, minor processing
prediction to be made about the average strength can be used to produce a stereo audio signal to
of the signal: theory predicts that the intensity of feed to the headphones, where the sounds in one
the Doppler signal is related to the quantity of
blood lying within the sensitive volume of the
Transmitter
Doppler beam. This forms the basis of the most amplifier
Oscillator
common method for volume flow estimation
using Doppler ultrasound. Finally, these spatial
fluctuations give rise to a speckle pattern in the sin wt cos wt
blood echo, analogous to, but of a much lower
strength than, the speckle pattern seen in the Receiver Demodulator
parenchymal echoes from a heterogeneous organ amplifier
Peter N Burns
17
distance from the transducer face and extends to intervals and the echoes are demodulated as they
the limit of the beams due to attenuation. The return (Figure 23). If the pulses are received in
detector will be sensitive to any moving target sufficiently rapid succession, the output of the
within this volume that produces an echo. Should demodulator (which compares the phase of the
there be moving solid structures as well as blood received pulse with that of the oscillator) consists
(for example, from the pulsation of an arterial of a sequence of samples from which the Doppler
wall), low-frequency Doppler shifts are obtained signal can be synthesized. The same transducer is
whose strength is much greater than that of the generally used for transmitting and receiving. The
blood flow itself. This may be more than an range in tissue at which Doppler signals are
inconvenience: if the dynamic range of the detected can be controlled simply by changing the
receiver is limited, overloading of the demodulator length of time the system waits after sending a
can occur, with the result that part of the blood pulse before opening the gate that allows it to
flow signal itself is lost. For this reason most receive. The axial length of the sensitive volume
instruments incorporate high-pass filters that help thus produced is determined by the length of time
eliminate Doppler signals below a certain for which the gate is open. Figure 24 shows that
predetermined frequency (typically 25-250 Hz). the electronic gate is generally placed after the
Even where clutter is not a problem, the presence demodulator and is governed by these two delays,
of several vessels within the sensitive volume which are under the control of the operator. A
gives rise to a superposition of several Doppler master clock ensures synchrony between the
signals. If these are simply an artery-vein pair (say emission of pulses and the operation of the delays
the carotid artery and jugular vein), the directional and gates. Quadrature detection, as before,
resolution of the spectral display and the distinct produces a directional Doppler signal as the output
characteristics of arterial and venous flow allow of the system. In practice, although the range of
their identification. the sample volume from the transducer is under
the control of the operator, the form of the
In the upper abdomen, however, there are usually sensitive volume itself is influenced by a variety of
too many vessels present to allow continuous factors. The length of time for which the received
wave systems to be very helpful. The usual
solution is to confine continuous wave techniques 1. Transmit
to the examination of superficial structures, and to
employ a sufficiently high ultrasound frequency so
that attenuation limits the penetration of the beam
and hence the extent of the sensitive volume.
Thus, 7 MHz-10 MHz systems are often used
without imaging for the examination of the carotid 2. Wait 3. Receive
and superficial vessels of the limbs. Many
configurations of the continuous wave transducer
assembly have been made, allowing, for example,
probes to be clipped onto vessels at surgery. The
continuous wave method is also capable of very
high sensitivity to weak signals, so that it is Figure 23 The principle of the pulsed Doppler method. The
preferred for the examination of smaller vessels range of the flow-sensitive volume is determined by the
such as those found in the extremities. transit time of the pulse in tissue.
Peter N Burns
18
affected by the position of the sample volume in pulse to the target and back. This may remedy the
the beam as well as the transducer frequency and aliasing of the Doppler signal but creates a new
design. Some scanners using electronic beam ambiguity as to the location of echoes received
focusing adjust the focus of the beam to coincide when the gate is open. In effect, a second sensitive
with the location of the sample volume, thus volume is created, located somewhere along the
influencing its lateral extent. ultrasound beam. Signals are obtained
simultaneously from both locations. Judicious
One fundamental shortcoming of the pulsed operation can manipulate this second sensitive
Doppler system arises from the way in which the volume into a region from which no Doppler
audible Doppler shift is in fact made from a large signals are anticipated to arise. Other, more
number of discrete samples, one of which is straightforward, solutions to the problem of
created each time an ultrasound pulse is received aliasing are to lower the ultrasound frequency
by the transducer. Samples that are created rapidly
when compared with the rate of variation of the T/R Transmit CLOCK
Doppler shift signal itself have no problems: a switch gate
Peter N Burns
19
of real-time ultrasound imaging for such guidance;
the combination of real-time imaging and Doppler
techniques is referred to as duplex scanning. Most
commonly, duplex scanners consist of a
combination of real-time sector imaging and a
pulsed Doppler.
Peter N Burns
20
Doppler signal is acquired. Because many
mechanical scanners employ more than one
transducer for imaging, some of them are able to
use different transducers, and possibly different
frequencies, for the two functions of Doppler
interrogation and imaging. These might exploit the
superior performance of a swept focus annular
array for imaging and a single disk or dual element
(for continuous wave) transducer for Doppler.
Typical combinations might be 7 MHz-10 MHz
for imaging and 4-6 MHz for Doppler in the
carotid, or 5 MHz imaging together with 3 MHz
Doppler in the abdomen. Electronic sector
scanners (Figure 27b) are capable of switching
Figure 27a Duplex scan of ophthalmic artery
between imaging and Doppler modes at a
sufficiently high rate to permit real-time "duplex"
imaging at a somewhat reduced frame rate. make the positioning of the Doppler volume
Although this is sometimes at the expense of difficult.
signal-to-noise performance of the Doppler
system, the facility of simultaneous imaging and The linear array configuration with an offset
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Doppler is particularly useful when low angles of
insonation are desired for vessels lying parallel to
the transducer face. One ingenious approach to the
implementation of such a method is to employ a
number of elements within the linear array as a
"phased" system, delivering the transmit pulse to
each of the elements in the group with very small
successive delays, which have the effect of
steering the Doppler beam in a direction that
differs from that of the beams used for imaging
(Figure 27c). Such systems may be used in the
examination of the carotid and other superficial
vessels lying parallel to the skin surface.
Electronic arrays may also address the problem of
the different optimum imaging and Doppler
frequencies by employing sufficiently broadband
transducers so that the two functions can be served
by the same array operating at different
frequencies. The agility of the beam produced by
Figure 27 Four common configurations of the duplex such arrays is capable of providing imaging,
scanner. Doppler, and M-mode functions at such rapid
a: The mechanical sector scanner.
alternations as to allow real-time examination of
b: The electronically steered sector scanner. the heart. The curvilinear array of Figure 27d is a
c: The linear array with electronically steered Doppler useful compromise between the relative
beam. advantages of the of the electronic sector and
d: The curvilinear array. linear array duplex scanner. Using an array for the
pulsed Doppler system allows electronic control
of the lateral extent of the beam in the direction of
Doppler is useful where there are slow movements
the array elements, but places quite heavy
(such as those of respiration or of a fetus) that can
Peter N Burns
21
may be measured directly from the ultrasound
T/R Transmit
switch gate CLOCK image. Inevitably, errors are associated with the
measurement: the vessel axis may not lie exactly
Oscillator
within the scanned plane, the vessel may be
curved, or the flow may not be aligned with the
RF Demod-
n range
& length
axis of the vessel. As discussed below, the error in
amp ulator delays velocity estimation resulting from such an
inaccuracy is strongly dependent on the beam-
Transducer
vessel angle itself. Velocity should not be
estimated when this angle is above 60°. In
Rx Rx Rx Rx correcting for the operating frequency of the
gate gate gate
n sample
gate .... Doppler system, velocity estimates eliminate one
volumes
factor that may vary between individual duplex
Sample
instruments. Thus, even if a constant value of
Sample Sample .... Sample
& hold & hold & hold & hold insonation is used in the examination, the
estimated velocity is a better parameter to report
Filter Filter Filter .... Filter than Doppler shift frequency.
Peter N Burns
22
signals obtained over an entire cross-sectional from each of its range gates in the same period of
image. All that would be required is a scanning time. However, in order to obtain Doppler
arrangement capable of steering the Doppler beam information along a large number of scan lines so
and registering its direction, and a sufficient as to form an image rapidly enough to be part of a
number of range gates to map a single Doppler real-time system, a very large number of parallel
parameter (for example, the average Doppler shift channels must be used. It is prohibitively
frequency) from near the transducer face to the expensive in hardware and software to
deepest point in each scan line. If a duplex system manufacture the, say, 128 channels required to
were to be used, the Doppler information could be obtain Doppler signals from the entire length of
superimposed on the real-time image, with the the scan line simultaneously. Even if this were
different velocities encoded using a colour scale. possible, a simple calculation shows that the beam
This is the principle of colour flow mapping, but could not dwell for 10 ms on each line and still
produce a real-time Doppler image. What is
Scan Converter
required is a method for obtaining not necessarily
Digital the Doppler signal itself, but an estimate of a
&
control
Image Formatter Doppler parameter such as the instantaneous
average Doppler shift frequency, from the entire
Color
Display length of the scan line quickly and simultaneously
Doppler Pulse-echo
Autocorrelation Duplex without the use of parallel channels. The
Flow detector System autocorrelation detector serves precisely this
function.
Peter N Burns
23
For this reason, the method is sometimes referred conventional duplex scanning and spectral
to as a "moving target indicator." Although such a analysis.
device is capable in principle of yielding the
instantaneous Doppler shift along a whole scan
line after only three pulses (i.e., less than 1 ms at a SAFETY AND BIOLOGICAL EFFECTS OF
pulse repetition frequency of 4 kHz), generally ULTRASOUND EXPOSURE
between four and eight pulses might be used. An
important aspect of the performance of a moving American Institute of Ultrasound in Medicine
target indicator is its ability to detect the tiny (AIUM) Statement on clinical safety:
changes in phase between the Doppler samples
from successive pulses which correspond to "Diagnostic ultrasound has been in use for more
slowly moving targets. The longer the length of than 40 years. Given its known benefits and
time over which the Doppler signals are sampled recognized efficacy for medical diagnosis,
per line, the smaller the Doppler shift that can be including use during human pregnancy, the
detected. However, longer scanning times per line American Institute of Ultrasound in Medicine
of colour data leave less time to create each frame herein addresses the clinical safety of such use:
of the colour image. The problem of clutter is
crucial in such a system because the very large No confirmed biological effects on patients or
echoes from solid structures moving slowly can instrument operators caused by exposures at
inhibit the detection of the weaker Doppler shifted intensities typical of present diagnostic
echoes from moving blood. Colour flow mapping instruments have ever been reported. Although the
systems employ digitally controlled filters possibility exists that such biological effects may
designed to eliminate the effect of clutter (Figure be identified in the future, current data indicate
29). One requirement of a colour flow mapping that the benefits to patients of the prudent use of
system is that the beam remains stationary for a ultrasound outweigh the risks, if any, that may be
brief time, moves to the next scan line and present"
remains stationary there, and so on. In addition, Although over one million pregnant women now
the flow mapping function must be alternated with receive at least one diagnostic ultrasound imaging
conventional imaging. The agility of the examination each year, and several hundred
electronically switched beam of a linear array (or a investigations of bioeffects on plant and animal
hybrid of the two) is therefore ideally suited to tissue have been undertaken, there is still some
colour flow mapping. The superposition of flow uncertainty as to the nature of potential risk to
information as colours on a gray scale real-time living tissue during a clinical ultrasound
image presents the Doppler information in a novel examination. This uncertainty has become more
and appealing way. These systems are clearly pronounced with the advent of pulsed Doppler
well-suited to identifying the location of high- methods, including colour. There are several
velocity flow (such as in a stenosis) or of mapping possible reasons for this. First, the acoustic
the extent of flow in a certain region. However, the intensity averaged over time (the Spatial Peak
Doppler information presented is that of a single Temporal Average intensity, SPTA) is considerably
parameter encoded in colour, a parameter whose higher in pulsed Doppler mode with many duplex
value is changing rapidly and is derived from, but scanners than in most imaging instruments. One
does not describe, the full Doppler frequency survey reports values up to 750 mW/cm2 ISPTA,
spectrum. Therefore, it seems likely that spectral but some pulsed Doppler systems are known to
analysis should remain an essential component of deliver SPTA intensities as high as 1,000 to 2,000
most Doppler examinations, whether or not colour
flow mapping is included. Indeed, present colour mW/cm2. Second, the beam must be stationary
instruments offer the flow mapping facility as an during a Doppler examination will 'dwell' on a
addition to, rather than a replacement of, target area for a longer period than for imaging,
sometimes for a period of minutes. Finally, it is
Peter N Burns
24
widely felt that of all tissues, those of the fetus are centers on the possibility of temperature rise in
likely to be among the most sensitive to biological tissue. By reducing both SPTA intensity and
effects of ultrasound, and Doppler has begun to exposure time, the likelihood of such an effect
play a part in the ultrasound examination of the taking place can be minimized. As long as there is
fetus. Only recently has the U.S.Food and Drug the possibility of subtle effects on tissue from
Administration approved the marketing of a ultrasound exposure, however, it remains prudent
single-gate pulsed Doppler duplex system for fetal to employ as low an ultrasound intensity and as
use, bringing questions to many users’ minds as to short an examination time as are consistent with
whether this modality is indeed safe for clinical obtaining clinically useful data. At present, there
use. have been no independently confirmed significant
biological effects noted in mammalian tissues
There are two classes of interaction of ultrasound exposed to ultrasound SPTA intensities below 100
with tissue that it is relevant to consider. Heating mW/cm2 At this and many other institutions, the
is a consequence of the progressive absorption of exposure level of all examinations is limited to
ultrasound energy as it travels through tissue. Heat below this value.
production is affected by the tissue type as well as Calibration of machine intensity is not a trivial
the form and frequency of the ultrasound beam, procedure. Fortunately, the FDA requires
with higher frequencies associated with more rapid calibration of all ultrasound instruments before
absorption. Although fetal tissue is sensitive to they are marketed in the United States, so these
heat, it is generally assumed that induced data are known by the manufacturer and should be
temperature changes that are less than those of made available to the user. With the help of these,
normal diurnal variation (about 1°C) are of no it is a simple matter to reduce the output of the
consequence. Local temperature rise will increase Doppler system to the desired level, Using modern
with the SPTA intensity but will also be affected machines, it is our experience that all obstetrical
by physiological factors such as local blood flow. Doppler examinations can be performed easily at
SPTA exposure levels of less than 100 mW/cm2
Nonthermal effects in tissue can be caused by the
without noticeable loss of signal quality. Sensitive
growth of oscillating microbubbles in tissue fluids,
pulsed Doppler systems are able to function well
stimulated by the presence of the ultrasound field.
at exposure levels below those of ultrasonic fetal
Such stable cavitation can modify cell function or
heart monitors now in routine use.
destroy cells. However, stable cavitation requires
relatively long "on" times of the ultrasonic field.
In summary, concern over the use of Doppler in
These are found in continuous-wave but not
some clinical applications has been a consequence
pulsed Doppler systems. Finally, the potentially
of the relatively high acoustic output of some
more dangerous phenomenon of transient
duplex scanners designed for peripheral vascular
cavitation is certainly capable of destroying tissue
use rather than of any known risk of hazard. By
but can only occur at high instantaneous (that is,
adjusting the output of such systems to as low a
spatial peak temporal peak, SPTP) intensities.
value as possible and reducing Doppler
Transient cavitation is not known to take place in
examination time, such potential risk may be
tissue at diagnostic intensities. Furthermore,
minimized without prejudice to diagnostic quality.
conventional imaging employs higher SPTP
Precisely how such levels can be minimized is the
intensities than pulsed Doppler, so that if there is a
subject of the 'output labeling' standard currently
risk it will be greater for ultrasound imaging than
proposed by the AIUM and the FDA.
for pulsed Doppler.
Peter N Burns
25
BIBLIOGRAPHY
Kremkau, F.W. Diagnostic Ultrasound: Principles and Instruments. 7th edition, W.B. Saunders,
Philadelphia.
Acoustic Output Measurement and Labeling Standard for Diagnostic Ultrasound Equipment. AIUM
Rockville, MD, 1992.
Atkinson, P., Woodcock, J.P. (1982): Doppler Ultrasound & its Use in Clinical Measurement. Academic
Press, London.
Burns PN. Physical principles of Doppler ultrasound and spectral analysis. J Clin Ultrasound 1987, 15:
567-590.
Taylor KJW, Burns PN, Wells PNT: Clinical Applications of Doppler Ultrasound. 2nd edition, Raven
Press, New York, 1996.
McDonald, D.A. (1974): Blood flow in arteries. Third edition. lea and Febiger, London, 1990.
Gill RW, Kossoff MB, Kossoff G, Griffiths KA: New class of pulse Doppler ultrasound ambiguity at short
ranges. Radiology 173:272-275, 1989.
Phillips DJ, Green FM, Langlois GO, Roederer GO, Strandness Jr., DE: Flow velocity patterns in the
carotid bifurcations of young, presumed normal subjects. Ultrasound and Med Biol 9(1):39-49, 1983.
Phillips DJ, Beach KW, Primozich J, Strandness Jr., DE: Should results of ultrasound Doppler studies be
reported in units of frequency or velocity? Ultrasound and Med Biol 15(3):205-212, 1989.
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