Ultrasound Imaging

Generation of ultrasound

• The use of ultrasound in medicine became practical with the

development of piezoelectric transducers
• Piezoelectric means “pressure-electric”
• Piezoelectric substances change shape under the influence of an
electric field or when mechanically stressed.
 GENERATION OF ULTRASOUND
• Ultrasound waves are usually both generated and detected by a
piezoelectric crystal.
• The crystal deforms under the influence of an electric field.
• When an alternating voltage is applied over the crystal, a compression
wave with the same frequency is generated.

• Generally used piezoelectric materials are: PZT and PVDF

(polyvinylidene fluoride)
• The thickness of the crystal determines the frequency of the scan head.
• Low Frequency 2.5 - 3 MHz
• High Frequency 10 MHz
 GENERATION OF ULTRASOUND
• There are naturally occurring piezoelectric crystals as well as synthetic crystals
Naturally occurring crystal
• Quartz
• Rochelle salt
• Lithium Sulfate
• Topaz
• Cane sugar
• Tourmaline
• Dry bone
Synthetic (Man-made) crystals
• Lead zirconate titanate (PZT)
• This is the most popular material for medical ultrasound
• Barium titanate
 GENERATION OF ULTRASOUND
• The frequency of a transducer is
determined by its mechanical
properties and the shape of the
crystal.
• The most important factor is the
thickness of the crystal.
• The focal zone is usually noted on the transducer
• It is important that the structure of interest be placed
in the focal zone to reduced loss of structural details
• The ultrasound beam has two zones:
• The near zone (Fresnel zone)
• Area closest to the transducer face
• The far zone (Fraunhofer zone)
• The far field diverges rapidly and degrades the ability to
define small structures
• The point at which the far field begins depends on the size
of the transducer in relation to the frequency (wavelength)
of the crystals
• Focal planes are usually labelled as short, medium or
long
• Improper use of a transducer or failure to adhere to
the physical applications result in degradation of the
image
 U/S MODES
• Three primary ways to display
echo information:
• A-MODE
• B-MODE
• M-MODE
• These various modes show
returning echoes in different
ways
A-MODE

• A-Mode (Amplitude mode) is the

display of amplitude spikes of
different heights.
• It measures the arrival time of the
echoes relative to the time the pulse
was transmitted
• It is used for ophthalmology studies.
• A-Mode consists of an x and y axes,
where x represents the depth and y
represents the Amplitude.
• can be used to judge the depth of
an organ and differentiate cystic
from solid masses.
 A-MODE
• A-mode (Amplitude-mode) ultrasound is used to judge the
depth of an organ, or otherwise assess an organ's
dimensions.
• Display of echo amplitude (Y-axis) versus distance (X-axis)
into the tissue, which is related to elapsed time and the
speed at which ultrasound propagates in the tissue.
• Sometimes used to calibrate the other modes.
• A-mode ultrasound is a relatively simple technic that can
differentiate cystic from solid masses.
• The A-mode scan had also been used for early pregnancy
assessment (detection of fetal heart beat), and placental
localization.
• Also used to test the symmetry between left and right
hemispheres of the brain.
• The distance between the transducer and a structure determines
where an echo is seen along the time axis
• The time elapsed from the transmission to the return of the signal is
converted to distance
• The speed of sound in tissue is ≈ 1540m/sec, thus the time it takes for
the echo to return to the transducer represents the distance
Information in A - Mode
• reflector distance
• relative amplitude of echoes
• whether a structure is echogenic
or anechoic
Advantages of A-Mode:
• precise information on structure
dimensions;
• inexpensive, easy to produce;
Disadvantages of A-Mode:
• only one dimensional (distance
from the transducer)
• no recording of motion patterns;
 B-MODE

• B-Mode, or Brightness Modulation, is the display of

2D map of B-Mode data,
• and is the most common form of ultrasound imaging.
• Unlike A-Mode, B-Mode is based on brightness with
the absence of vertical spikes.
• Displays image as large and small dots.
• Large dots represent the strong echoes and small dots
represent the week echoes.
• The brightness of dots depends upon the amplitude or
intensity of the echoes.
• There is no y axis on B-Mode, instead, there is a z
axis, which represents the echo intensity or
amplitude, and a x axis, which represents depth.
• B-Mode will display an image of large and small dots,
which represent strong and weak echoes,
respectively.
 B-MODE
• This form of display (solid areas
appear white and fluid areas
appear black) is also called gray
scale.
• The B-mode scan is the basis of
2D scanning. 
 M-MODE
• M-Mode, or Motion Mode (also called Time Motion or
TM-Mode),
• It is the display of a one-dimensional image that is used
for analyzing moving body parts commonly in cardiac
and fetal cardiac imaging.
• This can be accomplished by recording the amplitude
and rate of motion in real time by repeatedly measuring
the distance of the object from the single transducer at a
given moment.
• M-mode (motion mode): Takes a slice of a B-mode
image over time. Often used in TTE. Useful to assess
lung sliding for pneumothorax.
• Can image moving tissue boundaries by stacking A-mode
scans obtained at different times on top of each other.
 M-MODE
ADVANTAGES OF M-MODE
• Excellent temporal resolution
• Precise information on reflector motion
• Precise information on structure dimensions
• Inexpensive, simple to produce
 D-MODE
D-mode (D=Doppler)
• This imaging mode is based on the Doppler effect, i.e. change in
frequency (Doppler shift) caused by the reciprocal movement of the
sound generator and the observer.
• Diagnostic ultrasound uses the change in frequency of ultrasound
signal backscattered from red blood cells.
• The frequency of the reflected ultrasound wave increases or
decreases according to the direction of blood flow in relation to the
transducer.
 D-MODE

• D-mode (doppler): Detects flow to or away from transducer.

• Useful to find and define vessels, flow across valves
• Color
• → direction and velocity are color coded and superimposed on B-mode
image. “BART” (Blue is Away from probe, Red is Towards)
• Power → detects very low flow but not direction, useful in vascular
compromise
• Spectral → velocity presented graphically on a timeline
 Types of Doppler
• Doppler Duplex
• Doppler Duplex technique is based on the simultaneous B-mode real-time and
Doppler imaging.
• A gray scale display serves for the localization of flow measurement site.
• Both spectral Doppler techniques (Continuous-Wave and Pulsed) can be used
in Doppler Duplex imaging
CW Doppler (Continuous-Wave Doppler) (CWD)
• This imaging mode requires two piezoelectric crystals.
• One continuously transmits and the other one receives the Doppler
signals along the scan-line.
• CWD is very useful in high velocity signals recording. It defines blood
flow direction but has no value in Doppler signal source identification.
PW Doppler (Pulsed-Wave Doppler) (PWD)
• The same piezoelectric crystal transmits and receives the ultrasound signal.
• The reflected signal returns to the transducer after a definite delay that is known
as pulse repetition frequency (PRF).
• PWD allows measurement from a small, specific blood volume (depth of interest),
which is defined by a sample volume.
• It provides both blood flow direction and precise determination of of Doppler
signal source.
• The main limitation is failure to display the high velocity signals.
• The maximum detectable frequency shift (the Nyquist limit) is determined by the
value of half the PRF. After the velocity exceeds the limit, aliasing occurs 
Color Doppler
• Color Doppler imaging is based on the PWD assumption. However, in
Color Doppler imaging, multiple sample volume are evaluated along
each scanning line.
• Velocities are displayed using a color scale.
• Velocities toward the transducer are red, and velocities away from the
transducer are blue. 
Power Doppler
• Power Doppler is a variant of Color Doppler technique which displays
the magnitude of the Doppler signal rather than the Doppler
frequency.
• It is often used to increase sensitivity to low flows and velocities.
• Power Doppler does not display flow direction or different velocities
 Ultrasound equipment
Most ultrasound machines have the
following components in common:
• A pulser (transmitter) which generates
pulsed echo in brief bursts
• A transducer which converts electrical
energy to acoustic pulses and vice versa
• A receiver which detects, compresses
and amplifies signals returning to the
transducer
• A display which displays the signal in the
brightness B-mode, the motion M-mode
and the amplitude A-mode
• A memory which stores still and video
images
 PARTS OF THE ULTRASOUND UNIT
The basic components of the
sonographic equipment
include:
• Transducer
• Pulse generator
• Time-gain compensator
• Digital scan conversion and
memory
• Image processor
• Display
 THE TRANSDUCER
• Also called the probe or scan head
• The most important part of the u/s equipment
• Can be seen as the mouth and ears of the machine
• Capable of producing ultrasound waves and receiving returning echoes
• Contains the piezoelectric material
• When electric current is applied, they change shape rapidly
• When sound waves hit the crystals, they emit electric currents
THE TRANSDUCER

• The transducer has 5

main components
• PE crystals
• The Matching layer
• Backing layer
• Acoustic lens
• The transducer casing
• The electronic cable
 THE TRANSDUCER
• Ultrasound transducers are made of a transducer head, a connecting wire
or cable and a connector, or a device that connects the transducer to the
ultrasound machine.
• The transducer head has a footprint region where the sound waves leave
and return to the transducer.
• It is this footprint region of the transducer that needs to remain in contact with the
body in order to transmit and receive ultrasound waves.
• A gel is applied to the skin/mucosa surface of the body to facilitate transmission of
ultrasound waves given that sound waves do not transmit well in air.
• Each transducer also has a transducer (probe) marker located next to the
head of the transducer in order to help identify its orientation (Figure 2.2).
• This probe marker can be a notch, a dot or a light on the probe’s head.
• The use of this probe marker in handling the transducer and its orientation will be
further discussed in the following chapter
THE TRANSDUCER
THE TRANSDUCER
 Structure of the Probe
The transducer has 5 main components
1. The transducer crystal (PE crystal)
 Produces sound waves and receives the returning echoes
 the same crystals is used to send and receive sound waves.
 Structure of the Probe
2. The Matching Layer
 Provides acoustic connection between the transducer element and
the skin
 b/c the PE is solid with high density, it has impedance that is 20x that of tissue
 Without compensation, about 80% of the u/s will be reflected back at the skin
boundary and most of the u/s beam will not enter the body
 The matching layer is made of material with acoustic impedance
between that of PE and the transducer face
 This layer therefore functions to reduce the reflection of u/s at the
transducer element surface
 Thereby improving or maximizing transmission of produced u/s into the tissue
Structure of the Probe
3. Damping material
• Also called backing material
• Seen behind the PE crystal.
• It determines the bandwidth
• Improves resolution
• Reduces pulse duration
• Akin to parking foam/rubber around a bell
that is rung by a tap with a hammer
• This reduces the time the bell rings after
the tap
• The rubber also reduces the loudness of
the ringing
Structure of the Probe

4. Acoustic Lens
• Focuses the generated u/s waves
TRANSDUCER TYPES
• Transducers are produced in an array of shapes, sizes and frequencies
and are adapted for specific clinical applications.
• In general, transducers for cardiac applications have small footprints.
• Vascular transducers have high frequencies and are linear in shape
• Obstetric and abdominal transducers are curvilinear in footprint
shape in order to conform to the shape of the abdomen
• Linear transducers produce sound waves
that are parallel to each others with a
corresponding rectangular image on the
screen.
• The width of the image and number of scan
lines is uniform throughout all tissue levels.
• This has the advantage of good near field
resolution.
• Linear transducers are not well suited for
curved parts of the body as air gaps are
created between the skin and transducer
• Sector transducers produce a fan like image that is narrow near the
transducer and increase in width with deeper penetration.
• Sector transducers are useful when scanning in small anatomic sites,
such as between the ribs as it fits in the intercostal space, or in the
fontanel of the newborn.
• Disadvantages of the sector transducer include its poor near field
resolution and somewhat difficult manipulation.
THE TRANSDUCER
• Curvilinear transducers are perfectly adapted for the abdominal
scanning due to the curvature of the abdominal wall.
• The frequency of the curvilinear transducers ranges between 2 and 7
MHz.
• The density of the scan lines decreases with increasing distance from
the transducer and the image produced on the screen is a curvilinear
image, which allows for a wide field of view
THE TRANSDUCER
• Transvaginal transducers, like other endocavitary transducers, have a small
footprint and their frequencies are typically in the range of 5-12 MHz.
• They are designed to fit in small endocavitary spaces with the footprint at
the top of the transducer (transvaginal) or at the dorsal aspect of the
transducer (rectal).
• When performing a transvaginal ultrasound examination, a clean condom,
or the digit of a surgical rubber glove, should cover the transvaginal
transducer.
• Ultrasound gel should be placed inside and outside the protective cover in
order to facilitate the transmission of sound.
THE TRANSDUCER
• Ultrasound Transducers
Transducer probes come in many shapes and sizes,
• The shape of the probe determines its field of view, and the frequency
of emitted sound waves determines how deep the sound waves
penetrate and the resolution of the image.
• In addition to probes that can be moved across the surface of the
body, some probes are designed to be inserted through various­
openings of the body (vagina, rectum, esophagus) so that they can get
closer to the organ being examined (uterus, prostate gland, stomach);
getting closer to the organ can allow for more detailed views.
THE TRANSDUCER
 ULTRASOUND KNOBOLOGY
Controls of the Ultrasound Equipment
• Ultrasound equipment has a wide array of options and features.
• These features are typically operated from either the console of the
ultrasound equipment, a touch screen monitor or a combination of
both.
• The basic controls in ultrasound scanning are the following:
 ULTRASOUND KNOBOLOGY
• Power or Output Control:
• This controls the strength of the electrical voltage applied to the transducer crystal at
pulse emission.
• Increasing the power output increases the intensity of the ultrasound beam emitting
and returning to the transducer, thus resulting in increase in signal to noise ratio.
• Increasing the power results in an increase in ultrasound energy delivered to the
patient.
• It is therefore best practice to operate on the minimum power possible for the type
of study needed.
• Resorting to lower frequency transducers can help achieve more depth while
minimizing power output
 ULTRASOUND KNOBOLOGY
Depth:
• The depth knob allows you to
increase or decrease the depth of
the field of view on the monitor.
• It is important to always maximize
the area of interest on your
monitor and decrease the depth
of your field of view, which
enlarges the target anatomic
organs under view.
Gain:
• The gain knob (similar to a volume button in a radio set) adjusts the
overall brightness of the image by amplifying the strength of the
returning ultrasound echo
• The overall brightness of the image can be increased or decreased by
turning the gain knob clockwise or counterclockwise respectively.
Time-Gain-Compensation
• TGC compensates for tissue
attenuation •
• Rate of TGC is often called the
“slope” •
• Higher attenuating tissue needs
steeper slopes •
• Higher frequencies need steeper
slopes
• Focal Zones:
• The focal zones should always be placed at the depth of interest on
the ultrasound image in order to ensure the best possible lateral
resolution.
• Multiple focal zones can be used to maximize lateral resolution over
depth; however this will result in a slower frame rate and is thus less
desirable when scanning moving structures such as in obstetrics or
the fetal heart specifically.
• Freeze:
• The freeze knob allows the image to be held (frozen) on the screen.
• While the image is frozen measurements can then be taken and organ
annotations can be applied to the image before saving it.
• Furthermore, the option to “cineloop” (scroll) back to previous time
frames is an option that is available on most ultrasound equipment.
• This is a very important function in obstetric ultrasound imaging, as it
assists in capturing frames during fetal movements, such as
measurement of long bones.
• Trackball:
• The Trackball or Mouse pad is used for moving objects on the monitor
and for scrolling back in freeze mode.
• It has a multi-function and can be used in conjunction with caliper
placement, screen annotation, or moving the zoom or Doppler boxes
to the desired location.
• Zoom:
• Some ultrasound equipment has this function, which allows
magnification of areas of the ultrasound image displayed on the
monitor in real time.
• The trackball is used in conjunction with the Zoom knob to choose the
area for magnification.
Measurement:
• The measurement function or knob can also be displayed as Measure or Cal
(Calculation) on the ultrasound console.
• This function allows the operator to measure, in different formats, various
objects on the screen.
• When the measure button is pressed, a caliper appears on the screen. Use the
trackball to move the caliper to the desired location and set it.
• Once set, a second caliper appears, which can be set in similar fashion.
• Stored nomograms within the ultrasound equipment allow for determination
of gestational age and estimation of fetal weight when various fetal biometric
parameters are measured.
• Image artifacts are commonly encountered in clinical ultrasonography
and may be a source of confusion.
• Some artifacts may be avoidable and arise secondary to improper
scanning technique.
• Other artifacts are generated by the physical limitations of the
modality.
• US artifacts can be understood with a basic appreciation of the
physical properties of the ultrasound beam, the propagation of sound
in matter, and the assumptions of image processing.
 ARTIFACTS IN ULTRASOUND
• US artifacts may arise secondary to • Examples of artifacts encountered
• errors inherent to the ultrasound beam routinely include:
characteristics, • The beam width
• the presence of multiple echo paths, • side lobe
• velocity errors, and • reverberation
• attenuation errors. • comet tail
• Recognition of these artifacts is • ring-down
important because they may be clues • mirror image
to tissue composition and aid in • speed displacement
diagnosis. The ability to recognize • refraction
and remedy potentially correctable • attenuation
US artifacts is important for image • Shadowing and
quality improvement and optimal • increased through-transmission
patient care. artifacts
 ARTIFACTS IN ULTRASOUND
• hardware-related artifacts
• transducer-related artifact
• multipath artifact
• speckle artifact
• speed displacement artifact
• side lobe artifact
• twinkling artifact
 ULTRASOUND BASIC RULES AN
SCANNING PROTOCOLS
• The practice of ultrasound as well as its use in medicine require that
the user has a thorough knowledge of gross/micro anatomy, applied
anatomy, pattern recognition and pathology.
• To make meaningful contribution, the user should go beyond pattern
recognition which refers to the memorization of an ultrasound image
of a targeted structure (textbook picture) and learning the
manoeuvres and techniques necessary to acquire the image
• To advance beyond the pattern recognition mode, a thorough
knowledge of applied anatomy combined with a basic understanding
of how a 2D ultrasound image represents a 3D anatomical structure is
needed.
BASIC RULES
There are some basic rules that must be adhered to while scanning.
They include:
• Image Orientation
• Ultrasound orientation is essential to understand what is being seen
in ultrasound image.
• There are two key aspects:
• how the indicator is oriented relative to the screen and
• how the probe and indicator are placed and oriented relative to the patient
Indicator‐to-Screen Orientation
• There are two rules for indicator-to-screen orientation in standard ultrasound imaging
• The top of the screen is closer to the probe. Bottom of the screen shows structures farther
away from the probe.
• The left side of the screen, as it is viewed, corresponds to the side of the probe marked with
an indicator.
• Imaging performed by cardiology specialists uses a different and opposite convention for rule
2, which will be discussed in more depth later.
• The "indicator" may differ widely between manufacturers, and is typically a bump or a
groove. It is important to verify your orientation prior to beginning any exam. This should be
done by placing a small amount of gel on the side of the probe where you believe the
indicator to be, and confirming that the side with the gel corresponds to the left of the screen
as it is viewe
 ULTRASOUND BASIC RULES AN SCANNING
PROTOCOLS
STARTING AN EXAMINATION
• Before starting an ultrasound examination, it is important to ensure that essential
information about the patient is entered into the ultrasound equipment in order to be able to
• save ultrasound images on the hard drive of the ultrasound machine,
• accurately calculate gestational age in pregnancy and
• print ultrasound images for documentation purposes.
• Minimal relevant information that is required to be entered includes the
• patient’s name,
• date of birth and
• first day of the last menstrual period.
• On many ultrasound equipment, a knob identified as “Patient or Start” leads you to this
screen where this information can be entered.
• If you do not enter this information or any other patient identifier at the initiation of your
examination (patient name); most ultrasound systems will not allow you to print or save an
image from your examination
DOCUMENTING AN EXAMINATION
• An ultrasound report is required at the conclusion of the ultrasound
examination.
• It is important to know that image documentation is an essential
component of the ultrasound examination and report.
• Images can be produced in paper format or stored digitally on the
ultrasound equipment.
• Several ultrasound systems have knobs for images, which can be
formatted to allow for printing on a thermal printer and for saving a
digital copy in a DICOM format on the equipment hard drive
• The operator also has the option of downloading and saving a study
on an external hard drive or a USB jump drive.
• This is an important function in the low-resource setting as it allows
for exchange of cases for educational and consultative function.
• Typically these knobs can be formatted for these functions, such as for
thermal paper printer, for saving on the hard drive and for
downloading to the USB outlet.
• A permanent copy of the ultrasound report, including ultrasound
images, should be kept and stored in accordance with national
regulations.