State

Donald G. Mitchell, MD

of the

Art

Color Doppler Limitations,

Imaging: Principles, and Artifacts

blood cells that to the ultrasound cells are moving are moving relative beam. If the blood toward the source

C
the

OLOR Doppler (CD) combines in a single abilities of ultrasound

imaging modality (US) to im-

age

tissue

flow. CD information

and to investigate blood images consist of Doppler

that is color-encoded

and

superimposed

on a real-time

B-

mode gray-scale image (1-5). In response to reports that advocate the use of CD images to quantify cardiac disease (6-9), some technical limitations of CD imaging have been re-

ported

in the

cardiology

literature

(10-13). There has been a paucity of reports regarding technical issues of CD imaging outside the heart, how-

ever. value, been

While color saturation, pixel and color distal to plaque have used recently to grade carotid
(14), findings dependent such as these on the angle of

stenoses are highly

flow
as well

relative

to the and

ultrasound
other

beam,
operatorof this

as numerous variables. The

dependent
dent

operator-indepenpurpose

report
ness

is to raise
regarding

the
the

level

of awareof

determinants

CD image findings mote its appropriate

and thereby use.

pro-

PRINCIPLES Pulsed The changes Doppler frequency when of ultrasound

it is reflected from red

(transducer), the frequency of the reflected sound will be increased, whereas if the cells are moving away from the source, the frequency will decrease. The Doppler shift frequency is the difference between the frequency of the transmitted ultrasound and the frequency of the reflected ultrasound. This frequency is proportional to the velocity component aligned with the axis of the ultrasound beam (15-17). Since the strength of the Doppler signal is much weaker than that of the low frequency shifts from slowly moving tissue, a high-pass filter (eg, wall filter) is often used to allow only the higher frequency shifts to pass. If this is not done, the resulting clutter might overwhelm the receiver, preventing proper analysis of the Doppler spectrum (5,15,17). With pulsed Doppler, a discrete burst of ultrasound is emitted. After a specified delay, Doppler information is sampled for a brief interval of time. Because the speed of sound is relatively constant in the human body, the location of Doppler shifts can be determined from the delay be-

Figure
Doppler

1.
data

Diagram
for CD

of the acquisition

of
boxes Doppler. each line by the and the is the

imaging. Solid indicate range gates for multigate Several pulses are transmitted for of Doppler data. The rate is defined pulse repetition frequency (PRF), duration of sampling for each line

dwell

time.

With

some

CD systems,

a sepato sysare

rate sweep of one pulse per line is used acquire B-mode information. With other tems, Doppler and B-mode information obtained line by line.

tween

production

of the

sound

and

Index
trasound (US), Ultrasound

terms:
(US), physics (US),

Ultrasound
Doppler
#{149} Ultrasound

(US),
studies (US), characterization

artifact
#{149} Ultrasound

#{149} Ul-

technology

tissue 177:1-10

Radiology

1990;

its detection. In clinical practice, a Bmode US image is usually used to specify the location of Doppler interrogation, the range gate. The size of the range gate is determined axially on the basis of the duration of the ultrasound burst and the sampling interval, and laterally on the basis of the thickness of the ultrasound beam (15-17).

Doppler consists of several range gates along a line. This information can be color encoded and superimposed on a real-time M-mode image, which can depict Doppler shift profiles across vessels or through valves

(4).
Two-dimensional Doppler mation can be obtained by multigate Doppler technique inforusing a to

sweep across 1). Especially

sary used for this. method

an area of interest (Fig fast sampling is necesThe most of rapid commonly sampling for

CD imaging is autocorrelation, ed from methods used to detect

ing objects with autocorrelation, plied and summed

adaptmov-

From Main

the and April

Department Bldg. Thomas Jefferson

of Radiology, Jefferson Medical revision June to the College.

10th University 11th

Real-Time

Two-dimensional

Floor Hospital

Doppler
ReMay 7.

radar (2,4,5,). With the signal is multiover a series of

and
ceived

Sansom
revision

Sts,
27, received

Philadelphia,
1990; requests

PA
4; accepted

19107.
June

If Doppler

information

is sampled
Abbreviations:
pulse repetition

requested author.

23;

Address reprint c RSNA, 1990

during several intervals following each ultrasound pulse, multigate Doppler can be performed. Multigate

CD
frequency.

color

Doppler,

PRF

time-shifted

versions

of itself.

By so

to be considerably

less

than

the

peak

doing, motion can be detected, and an estimate of the mean frequency shift is obtained. The amount of fluctuation is often referred to as vanance and is color encoded on many systems (4,5). There are alternatives to autocornelation for creation of a CD image, but discussion of these

frequency.

The

difference

between

the mean and peak frequencies depends on the range of Doppler shifts within the sample volume. While some investigators recommend measuning peak frequency directly from color images (14), errors are likely to

across the mitral anulus during le) (5). Line-by-line interleaving possible but requires more rapid switching between Doppler and

systois B-

mode

pulses.

It is also

possible

to

methods is beyond the scope of this review. It must be emphasized that the data acquired for most CD images is different from that acquired for Doppler spectral analysis. For CD imaging, a single representative numben, usually the mean or a similar quantity, is assigned to a pixel, while the full spectrum of frequency shifts
is displayed in a Doppler spectrum.

occur if this is done. For most systems, B-mode and CD components of the image are acquired separately, during separate sweeps (5). This allows the use of dedicated ultrasound pulses for Doppler and B mode. It is also possible to steer the ultrasound beam so
that the angle of insonation is differ-

ent

for B-mode
of the three

and
image. to 32,

Doppler

compofor

nents usually

Several pulses, are necessary

The peak frequency shift at a given time is not directly related to the mean frequency shift or to the hue
intensity of color on CD images. In

or

each line of Doppler information, while one pulse per line is sufficient for B-mode imaging. Therefore, most of the acquisition time is devoted to
constructing may be offset the Doppler image. partially by using This a interof Figure 2. Longitudinal CD image of a tortuous common flow toward the transducer. carotid artery. the transducer; High Doppler Blue indicates red, away from frequencies

the

center

of large

vessels

with

plug

flow, where most flow is at a uniform velocity, the mean frequency is close to the peak. Nonuniform velocity

lower
component polating

line

density
of the the space

for the
image, between

Doppler
thus lines

are indicated
shade). The

by decreased
highest frequencies

saturation
in this

(pale
im-

within areas
cations,

a sample volume-such of turbulence; at curves,

or confluences; near

as in bifunvessel

Doppler
Separate color can

data.
sweeps for B mode and yield anomalous images in

age (*) correspond to regions where the angle between the ultrasound beam and the
blood flow is lowest, whereas lower frequencies correspond to flow that is nearly perpendicular to the beam. Where flow is perpendicular (arrows), a complex mixture

walls; or where sel changes-is spectral display ing. This causes

the diameter of a vesdepicted in a Doppler as spectral broadenthe mean frequency

which tissue position tral valve in diastole)

time different from

(eg, open is encoded

flow (eg, no

miat a
flow

of red and

blue

is observed.

a. Figure 3. relationship
carotid

b. Longitudinal between
the large

C.

duplex CD images of the proximal internal carotid color-encoded peak velocity, highlighted by a green
angle between the common and internal carotid

artery in tag, and

arteries has

two

different

patients;

the peak
caused

Doppler
internal

these frequency.
artery

illustrate the inconsistent (a) In a patient without

flow to be aligned with

disease

carotid

the ultrasound beam. This results in peak Doppler shifts as high as 10 kHz, as depicted in the Doppler spectral display at bottom. Note that flow velocity within the sample volume is relatively uniform, depicted as a clear window beneath the peak Doppler shift in the spectral display. Thus, peak and mean Doppler shifts are similar. In the image, Doppler shifts at or above 9.7 kHz have been encoded as green (arrow). The baseline has been shifted to the bottom to prevent aliasing. Note that a mechanical wedge has been interposed between the skin
and the just transducer below this to decrease value are the angle between the ultrasound beam and the common carotid indicated artery. (b) In a patient with wrapping angiographic eval-

idence
shifts

of a 90% stenosis

of the proximal
encoded

internal
as pale

carotid
red.

artery,
spectral

Doppler
display

shifts

at or above
site

6.4 kHz

have

been

encoded
at 9.8 kHz,

as green.

Doppler
around

(c) The

at the

in b aliases

most to the baseline. The peak Doppler frequency is thus nearly 16 kHz. Note that the flow disturbance has broadened the spectrum, in the window beneath the peak frequency. For this reason, the mean Doppler shift is significantly less than the peak. 2
#{149} Radiology

filling

October

1990

a. Figure artifact. 4. Longitudinal (a) The tissue

b.

duplex CD images of a normal brachial artery, acquired with excessive gain and power, show a color mirror-image deep to the brachial artery is encoded red. A spectral waveform is obtained from this region. There is no spurious color elsewhere in the image. (b) With power and gain reduced, color is confined to the vessel. The spectral waveform has higher amplitude than that in a but is identical in other respects.

(strength Green to encode mon use

of the signal). is often used information. in cardiology volume,

as a third color Its most comis to depict the

range
sample

of frequency indicate shunts

shifts
or variance,

within

a
which

helps across

disturbed or abnormal
with

flow such as valves. It

is

must be emphasized not synonymous

that variance turbulence

(4,5). Green may also be used to tag frequency shifts above a designated threshold, highlighting the areas of
most rapid flow. Again, the highest frequency as measured by means of green tagging is less than, and bears an inconsistent relationship to, the peak frequency shift (Fig 3).

a.
Figure 5. Longitudinal CD images of a brachial

b.
artery show the differential features of

flow separation and aliasing. V brachial vein. (a) During early diastole, some reversed flow is noted (arrows). Note that the sequence of color changes at the transition between antegrade and retrograde flow (pale red, deep red, deep blue, pale blue) matches the changes at the center of the color bar at the right. Thus, the center of the blue component of the image has the palest color. (b) During peak systole there is no retrograde flow. Decreasing the PRF (note the decreased Doppler shift range as indicated at the top and bottom of the color bar) has produced aliasing. Note that the sequence of color changes is now pale red, pale blue, and deep blue, indicating wraparound from the top to the bottom of the color bar. Thus, the center of the blue component of the image has the deepest color. With this instrument, the transition between pale red and pale blue at the alias frequency is highlighted by a red line (arrows) that is thinner than the color pixels.

CD Manifestation Mirror-Image
Reflection two strong
a delay,

of the Artifact

B-Mode

of ultrasound between specular reflectors causes

produces a mirror im-

which

age Mirror

of the

space
situated

between
beneath

the
them

two

re-

flectors,

(18).

process each echo for B-mode and Doppler information (3), allowing the use of a higher frame rate. This may lead to compromise in the optimum pulse length or beam characteristics for B-mode or CD imaging,

one direction and blue, the other direction. The Doppler shift, which indicates the component of velocity aligned with the ultrasound beam, is usually encoded as saturation of color. Decreased saturation (increased
whiteness) typically indicates higher

tery tion

images are caused

from the

of the subclavian by the specular

lung (19). Carotid

arreflec(20)

however. Color
There

Maps
are numerous strategies for

Doppler shading
as red

shifts toward
toward

(Fig 2). Alternatively, different colors,

yellow, may be used

such
to

and brachial artery mirror images can also occur (Fig 4). As this is a fundamental artifact of pulsed ultrasound, Doppler shifts from the mirror image are depicted by spectral analysis. Operators should suspect this artifact when Doppler shifts deep to a vessel
mirror those within the vessel. Scan-

facilitate
rapid Some

differentiation
flow in opposite instruments can

between
directions. also depict the

encoding the frequency, variance, and amplitude of Doppler shifts into color. Typically, red indicates flow in
Vtliim 177
.

ning from an angle that source vessel, or reducing

or Doppler the mirror gain, image. should

excludes the the power

eliminate

amplitude

of the

Doppler

shift

M..ml..r

r__1_1,..__.

Figure
liver the

6.

Oblique a deep
vena

duplex
the cava depth

CD images
ambiguity

of the
arti-

demonstrate inferior

fact. (a) With a spectral

field

of view,

flow
in red,

in
and

is depicted

waveform

is obtained.

(b) With

shorter depth (higher PRF), Doppler shifts from the inferior vena cava are mapped in a more superficial location, as if they originated from the liver. Notice that attenuation has produced a weaker Doppler signal, as depicted in the CD image and the spectral

waveform.
shown)

Decreasing
eliminated the

the far gain

artifact.

(not

DOPPLER Doppler
(Ahasing)

LIMITATIONS Ambiguity
upper shifts by because it is not posunambiguously a is faster than one-half forms Doppler an

Shift

The Doppler PRF limit for measuring

pulsed

Doppler

sible to measure frequency that

of the
Thus,

rate
Doppler

at which
shifts

it is sampled.
greater than

PRF/2 are wrapped around and depicted as if they were in the reverse direction (15-17). Most systems
allow the user to change the position

a. shifts may be encoded in a position

b. split between ing simultaneous red and blue, bidirectional mimickflow

of the

baseline

in the

Doppler

spec-

tral display so that Doppler shifts less than the PRF can be depicted in the correct direction (Fig 3). Aliasing is fundamental to pulsed Doppler and therefore affects CD images. With most color-mapping schemes, aliasing is depicted on CD images as an abrupt change between pale (highfrequency) shades of color, such as from pale red to pale blue. This can usually be distinguished from flow separation, in which deep shades of color are typically adjacent to each other (Fig 5). Use of the mean velocity for color encoding can result in less aliasing than might occur if peak frequency

where

there

is no flow,

if PRF

is high

enough (22). This artifact may occur with low-frequency transducers, high far gain, and high PRF (short depth) (Fig 6), but it is rarely a clinical problem because intervening tissue usually attenuates the echo amplitude sufficiently, causing these shifts to fall below the threshold for depiction.

(Fig

7). This

latter

appearance

is also

seen in axial images helical flow, where streamlines of flow

of vessels with two separate wrap around

each

other

as in a braid.

Helical

flow

Angle

of Insonation

With B-mode imaging the optimum angle of insonation is typically near 90#{176}, because reflections are strongest when the beam is perpendicular to the reflecting surface. This does not apply to Doppler US. This is because the Doppler shift is greatest when flow is aligned parallel to the ultrasound beam. As the angle of insonation relative to the axis of flow approaches 90#{176}, Doppler shifts decrease and may fall beneath the threshold for detection. On the other hand, a larger angle of insonation may be appropriate in some instances to reduce aliasing. With a large angle of insonation relative to the vessel, flow that is not parallel to the vessel walls will have more effect on CD images. Adjacent areas may be encoded with both red and blue. This may take the form of a diffuse mixture of red and blue, mimicking disorganized flow. Alternatively, the lumen of a vessel may be

is common distal to venous confluences such as the portal vein, in the proximal internal carotid artery, or in dilated tortuous vessels, because flow separation may result when the diameter of a vessel increases. The normal area of reversed flow in the carotid bifurcation (23) appears exaggerated at larger angles of insonation

(Fig

8).
it is likely that CD images

While

were used (5,21). Turbulent example, is characterized

locity as well as low-velocity

flow, for by high-yeand re-

are more accurate ages for estimating

blood flow, this

than the
has not

B-mode imangle of
been proved.

versed

components

of flow.

If the

One

must

be aware

that

CD imaging

peak velocity is used to encode color, high-velocity components will result in aliasing, and assignment of color will indicate flow in the opposite direction. The mean frequency, however, will be considerably less than the peak, so aliasing occurs less frequently.

does not eliminate errors in angle estimation. It is not known whether streamlines of flow as depicted on a velocity map correlate precisely with the true direction of flow. In addition, the angle as estimated from CD images represents a two-dimensional approximation of a three-dimension-

Depth

Ambiguity

a! vector. flow may

plane

The not

true angle lie entirely

image.

of blood within

the

of the

Reflections that originate deep to the field of view may arrive at the transducer after the next pulse has been emitted. These reflections may

Transducer
The

Geometry
beam
has skin

ultrasound

from

a lin-

be depicted
cation. 4 For

in a more
this reason,

superficial
deep Doppler

lo-

ear-array transducer angle relative to the

a constant surface. October 1990

#{149} Radiology

ducer will be intermediate the geometries of linear

transducers, depending

and
on

between sector
the radius

of curvature. The angle of insonation ear-array transducer can

by electronic and mechanical

from a linbe changed

meth-

ods. For the user, electronic beam steering is the most convenient, in that the angle of insonation for the Doppler component of the image can
be changed by than simply pushing a but-

ton
gles

(Fig
other

9). Steering

the

beam

at an-

90#{176} to the

transducer

surface

decreases the effective aperture and increases the beam thickness. This can degrade sensitivity and lateral resolution and increase artifacts from grating lobes (5). An alternative is to insert an anechoic wedge between the transducer and the skin to incline the whole linear array (Fig 3a). Disadvantages of a wedge include reverberations, attenuation, and increased distance between the target and the transducer,
a. which requires reduced PRF.

Spatial, Temporal, Resolution

The spatial and

and

Frequency

temporal

resolu-

tion of the flow map likely to be less than of the B-mode image

in CD images is the resolution on which it is

superimposed.
quency (Doppler)

Temporal
resolution

and

frein a CD

image are also likely to be less than those of the corresponding Doppler spectrum. The axial resolution of Doppler is defined by the size of the range gate.
Improving by decreasing axial the Doppler resolution size of the range

gate reduces the precision

ler b. C. Figure 7. Helical flow in dilated portal veins in two patients with portal hypertension. (a) Transverse duplex CD image shows that the directions of flow in the medial and lateral portions of the lumen relative to the ultrasound beam are different. Arrows indicate the direction of the axial components of flow in the portal vein. Spectral analysis reveals continuous flow. The direction of the Doppler tracing can vary if the range gate is moved across the lumen. (b) Transverse CD image at the confluence of the splenic vein (straight arrow) and superior mesenteric vein (caudal to this image). Curved arrows indicate the direction of the
axial components of flow in the portal vein. Doppler shifts vein

Doppler sensitivity and with which the Doppbe measured (5,15,16).

shift

can

coded as green. (c) Longitudinal cal flow (arrows).

CD image

of the portal

greater than in another

1 kHz patient

have been enshows heli-

One reason for this is because the signal-to-noise ratio is lower when a smaller volume is sampled. Reducing the range gate also reduces the time during which blood crosses the ultrasound beam. As red blood cells cross the beam, the amplitude of the echo increases and then decreases, broadening the Doppler spectrum. Because of this transit time effect, even a sin-

gle particle With a sector transducer, however, the angle is greatest at the center the image and least at the edges. ing of interpretation of flow direction,

moving

at a constant

ye-

Thus, a vessel that is parallel to the skin will appear blue at one end and red at the other and have no color or

a complex

mixture

in between

(Fig
transducregard-

9). While the er may cause Volume 177

use of a sector some confusion

#{149} Number

it may increase the likelihood of detecting Doppler shifts in vessels perpendicular to the skin. This is especially true in the abdomen, where it is often difficult to change the angle of the transducer relative to the area of interest. The geometry of flow mapping with a curved-array trans-

locity through an ultrasound beam produces a spectrum of Doppler shift frequencies. For B-mode imaging, resolution is improved by using a beam as thin as possible, to reduce beam-width effects. The thinner the beam, however, the more rapidly the echo amplitude changes as a particle crosses it. This results in a fundamental uncerRadinlnev
#{149} c

tainty

relationship between spatial shift resolution. Efforts to improve the spatial resolution of

and Doppler
Doppler

therefore

tend

to reduce

the

accuracy
can be

with
measured.

which
The

Doppler
uncertain

shifts
rela-

tionship ler shift reasons istics are spatial

between spatial and Doppresolution is one of several why optimal beam characterdifferent for B mode and
Doppler. The low a. b. 8. Transverse with different
(a) With

two-dimensional cause area where

resolution of Doppler may color to be encoded beyond

Doppler shifts are really

the

Figure quired
transducer.

CD images of the carotid bifurcation in an asymptomatic degrees of cephalic angulation. Red indicates flow away
the transducer inclined at approximately 600 relative to the

volunteer from the

skin,

ac-

present, perhaps observation that

accounting CD imaging

for the causes

a small

area of normal

overestimation of the size of the cardiac jets relative to estimates with angiography (10). In general, the jet area depicted by CD imaging is likely to be more dependent on instrument parameters than on vascular anatomy

reversed flow blue. (b) With the transducer indicated by the arrows.

along the posterior nearly perpendicular

wall of the internal carotid to the skin, helical flow

is depicted predominates,

in as

or physiologic characteristics. Analysis of Doppler signals by means of fast Fourier transformation

usually provides approximately 100

spectral
quency frame

lines

per

second,
of 40-80 imaging

with

a fre-

resolution rate of CD

Hz. The can vary

between 4 and The frequency

aging is highly

32 frames resolution
variable

per second. of CD imbut is usually

less than that single sample

of Doppler volume.

analysis

of a

a.

b.

POSTPROCESSING Color
The

versus
method

Gray

Scale
between

of deciding

color and gray scale for encoding each pixel is the source of some unique artifacts. There is no perfect method for this decision. The most

Figure 9. Longitudinal CD images of the common carotid artery (deep) and internal jugular vein (superficial) in an asymptomatic volunteer demonstrate the effects of transducer geometry on color mapping. (a) With a linear-array transducer, beam steering has been used to improve the angle between the vessels and the ultrasound beam. Flow velocity relative to the beam is similar at either end of the insonated segments of each vessel. (b) With a sector transducer, the direction of flow relative to the ultrasound beam is different at each end of the artery and vein. Furthermore, the color is palest at the ends of each vessel, where the angle relative to the ultrasound beam is smallest. Note that extension of color encoding beyond vessel walls, presumably caused by interpolation, does not occur at the center of the vessels, probably because the low Doppler shifts at the periphery of this portion of the yessels are not color encoded.

successful

strategies

use

echo

ampli-

tude, as well as Doppler frequency, to differentiate flowing blood from stationary fluid and moving solid tis-

sue. Myocardium,

vessel

walls,

perivas-

cular tissue, and moving viscera typically move slower than flowing blood and produce low-frequency Doppler shifts. These frequencies can be removed by means of wall filters,

moving
both

target
(2,4,24).

indicator
Unfortunately,

filters, information
blood and

or
these are Dopp-

filters
from

can
slowly

also

remove effective

flowing but

not
very

completely
strong

in removing

low-frequency

ler shifts. Various frequency-response curves for moving target mdicator filters can be used to vary the relationship of color encoding to
Doppler shift on the clinical High-amplitude frequency, application Doppler depending (2). shifts

a. Figure 10.

b.

CD images of a tissue-equivalent phantom obtained with high gain demonstrate suppression of color noise over echogenic regions by transducer motion. (Reprinted, with permission, from reference 25.) (a) With the transducer held stationary, color noise fills the far field of the image. (b) With slight transducer vibration, color is still present in the anechoic regions but is suppressed over the echogenic material. October 1990

#{149} Radiology

from moving tissue moved by a separate

signs a gray-scale

can also process

value

be rethat asre-

transducer

motion between color

(Fig and

10) (25).

nous

shunt

but

can

also

obscure

vas-

Depending
orities

on how

and

when
gray

priscale

to strong

flections but allows color signed to weak reflections some instruments, motion
be used to suppress especially color. high-amplitude

to be as(17,25). In itself can

This pro-

are set, a variety of artifacts cur. Many of these artifacts

ed to color noise, which

can ocare relatoccurs when

cular anatomy. Interpolation, used to improve

the color display.

or filtering, can be the appearance of

If a satisfactory

cess
where

involves shifts
noise in

suppressing are detected.

hyperechoic

color Thus,
areas may

the Doppler gain is too high or the Doppler reject too low. If echo intensity is used to suppress color, noise

frame rate is maintained by using a low line density, gaps between lines may be filled with interpolated data.
This may be useful for imaging cardi-

Doppler
color

may fill hypoechoic regions preferentially. Thus, setting the gain so

that not solid prevent tissue is free of color does fluid collections or

ac chambers

or large

vessels

but

inyesfill-

actually

be suppressed

by tissue

or

terferes with depiction sels. Spatial persistence ing in the small gaps

of small involves between

thrombosed

vessels

from

containing
color from of realnoise

adjacent
more press

pixels
cohesive color noise

of color
appearance.

to create can

a suponly

color (25,26). Fortunately, can usually be differentiated flow by careful inspection

A similar

technique, color
color

spatial that
(Fig

filtering,
by 14). displaying Temporal

time images, and firmed by means

(Fig 11).

this can be conof spectral analysis to by

pixels
pixels

are adjacent

to other
persis-

Pulsations that are transmitted hypoechoic tissue can be especially difficult to distinguish from flow means of CD imaging (Fig 12). Pulsed Doppler spectral analysis,
however, will reveal a Doppler trum indicative of transmitted tions rather than of flow (25).

tence involves averaging B-mode or Doppler information over several frames. The extent to which postprocessing affects the plex hemodynamics plored extensively. depiction has not of combeen ex-

Figure

11. noise.
tissue

a surgically
color
solid

Transverse duplex CD image of proved hematoma filled with Color has been suppressed over
because the reflections from it

specpulsa-

CD

PARAMETERS
(transducer) in several re-

Moving
with color

tissue
adjacent

is often
to areas

encoded
of rapid

are stronger. Thus, setting color gain and reject to avoid noise over solid tissue did not prevent color from filling anechoic regions. Note flow in the deep femoral artery (A). Lack of flow in the hematoma was confirmed by means of spectral analysis. (Reprinted, with permission, from reference 25.)

flow

associated
shunts

with

stenoses
This

or artephe-

The choice of carrier frequency is important

riovenous

(27,28).

nomenon

is manifested

as a diffuse

spects. As with B-mode US, penetration with CD imaging decreases with higher frequency. Thus, deep flow is

mixture of color, the extent of which is greatest during systole (Fig 13). This artifact can alert the diagnostician to the presence of an arteriove-

difficult to detect with high-frequency transducers because of limited penetration. On the other hand, Doppler shifts increase with higher carrier frequency. Thus, slow flow is more difficult to detect with low-frequency transducers because the

Doppler

shifts

are

lower.

Additional-

ly, flow aliases at a lower velocity with a high carrier frequency if PRF is kept constant. Jet areas from regur-

gitant
with plitude

or stenotic
low frequency,

valves

are

larger
because periph-

possibly at the

of increased

sensitivity

to lower-am-

ery of the
With
controlled

Doppler shifts jet (10,11).

most

instruments,
separately for

gain
B mode

is
and

Doppler. suppressed

Because over

color is typically especially bright

echoes, use of slightly high B-mode gain may decrease the presence of color noise over solid tissues. Exces-

sively high may suppress

Doppler justed timized a. Figure 12. Transverse duplex hypoechoic material. (Reprinted, Doppler reveals Doppler shifts the lumen of the aneurysm. (b) material because of transmitted
suppressed.

B-mode color
and color

gain, within
reject noise

however, vessels.
should be ad-

gain

so that
but

depiction
decreases

of flow
as gain
the PRF

is opis
is not

is minimized.

b. CD images of an abdominal aortic aneurysm surrounded by with permission, from reference 25.) (a) Single-gate pulsed from the low velocity of the echogenic material adjacent to A similar signal is obtained from the peripheral hypoechoic pulsations. These echoes are weaker, so color has not been

Cardiac

jet size

lowered (10-12,24). In most instruments

directly

controlled

by the

operator

but is adjusted automatically so that it is as high as possible for the depth of interrogation. PRF is also comD.J...1......-.
_

Volume

177

#{149} Number

monly velocity responding

tied

to the

frequency

shift PRF range

or corof

scale,

with a lower to a narrower

Doppler shifts. Thus, the scale by which Doppler shifts are color encoded changes with PRF and therefore with image depth (Figs 15, 16).
With many PRF, instruments, the wall fil-

color noise should be used. Users must be aware that this does not prevent mirror-image artifact (Fig 4) or localization of color noise within anechoic areas without flow (Fig 11), and they must be prepared to reduce

the gain further if these artifacts are suspected. For specific applications, additional adjustments may be necessary. The frame rate is affected by many factors. An increase in the field of

ter increases
creasing low-velocity

automatically
thereby components

with
preventing of a jet

in-

from being depicted (21). This may account for the observation that the apparent area of jets through stenotic or regurgitant valves is decreased when higher PRF is used (10,11). The dwell time, also referred to as ensemble length or packet size, is the
duration of Doppler sampling for

each
times

line

of sight.

Longer

dwell
to slow

improve

sensitivity

flow and accuracy of Doppler measurement and may thus improve the color component of a CD image
(5,21). The frame rate, however, be-

comes creases,
CD ing

slower thus

as the limiting

dwell the

time ability

inof
chang-

imaging to depict hemodynamics.

rapidly

CD
Users

IMAGING
should learn

TECHNIQUE
how to opti-

a.
Figure common 13. Tissue vibration from femoral vein. (Reprinted,

b.
an iatrogenic femoral arteriovenous with permission, from reference 28.) shifts fistula adjacent (a) Longitudinal in both directions. to the CD

mize
Doppler

B-mode
reject

gain,
on

Doppler
their system.

gain,
In

and

image
Spectral
id

shows
analysis is not

a diffuse
reveals obscured

mixture

of red and shifts is seen

blue more

(arrows) clearly

adjacent
Doppler

to the site of the fistula. image, since the sol-

high-amplitude, by color encoding.

low-frequency

most cases, and lowest

the highest reject that

Doppler does not

gain cause

(b) The origin

tissue

of the Doppler

on the B-mode

a.
Figure 14. Oblique CD has been set to maximize images flow of a hepatic vein depiction without

b.
demonstrate color noise. the Note

C.

effects of spatial filtering of CD that pixels adjacent to the lumen

mapping. of the

(a) With spatial hepatic vein have

filtering, gain been encoded

with

color.

(b) Same

image
of printing but gaps

as a but without
from between

spatial

filtering.

Color
as b but

noise
with

appears
gain

in the image.
to eliminate

The

uneven
color noise.

appearance
Color

of the images
is now restricted

in a
to the

and b is an artifact lumen of the vessel,

video. (c) Same image color are noted.

reduced

#{149} Radiology

October

1990

view will decrease the frame rate because a deeper field of view requires a slower PRF, and a wider field of
view (or wider sector angle) requires

dominal plications,

and

peripheral however,

vascular it is often

ap-

Doppler (Fig 16).

value

assigned

to a pixel

more lines of information An increase in the line which improves lateral

also decreases the are used, frame

per frame. density, resolution,

rate. To de-

necessary to detect slow flow or resolve several small vessels. To accomplish this, frame rates tend to be slower than for cardiac applications.

Deep

flow,

such

as in the

abdo-

Slow

flow

must

be detected

for ef-

tect
dwell

slow
time

flow,

lower

PRF
both

and

longer

of which

decrease the frame rate. Thus, a rapid frame rate can be maintained only at the expense of spatial resolution (line
density), time), and Doppler field accuracy (dwell of view (depth and

width). Therefore, users must mine which of these parameters

deterare

most important for diagnosis. For cardiac applications, temporal resolution of flow tends to be more important than spatial resolution. For ab-

fective CD imaging of small arteries and most veins. High-frequency transducers should be used. Use of the wall filter should be minimized. In many cases this involves decreasing the PRF. Increasing the dwell time also improves sensitivity to slow flow. These changes also increase the sensitivity of the image to transducer and tissue motion and decrease the frame rate. Thus, slow scanning is usually necessary for satisfactory imaging of slow flow. Increased sensitivity to slow flow may decrease the

men, usually requires low-frequency transducers for detection. Unfortunately, this limits the sensitivity to slow flow. Increasing the dwell time may help. Unfortunately, long dwell time and low PRF (necessary to im-

age

deep

structures)

both

limit

the

frame rate, which makes scanning the abdomen difficult. For this reason, the narrowest possible window for color encoding should be used for deep abdominal CD imaging. Small vessels, such as in the kidneys and scrotum, can be detected best by increasing the slow flow, as described filters and persistence sensitivity above. should to Spatial not be

used,

but

temporal

persistence

might

help. High spatial resolution is not necessary to detect flow in small yessels, but vessels beneath the resolution limits of the system will be color

encoded

as if they

were

larger,

and

small vessels near each other will not be separated. One must be aware that the diameter of vessels cannot be measured accurately by noting the

width of color the resolution

Doppler,

encoding, limitations

because of color
and slow

of

interpolation,

flow at the periphery of vessels. The presence of flow within small vessels should be confirmed by means of
spectral analysis, as depiction by imaging may be unconvincing. While CD imaging can facilitate detection

a. b. Figure 15. Longitudinal CD images of a brachial artery during peak ual as in Fig 5) demonstrate the effects of PRF on color encoding and tings are similar to those in Figure Sb, except that increasing PRF by medium flow setting has eliminated aliasing. Note that the Doppler dicated at the top and bottom of the color bar, is higher than in Figure a except that PRF has been reduced by increasing the depth, causing

systole (same individaliasing. (a) The setchanging from low to frequency range, as in5b. (b) Same image as
aliasing.

of small
likely

vessels,
to be more

spectral
sensitive

analysis
once

is
the

proper

range

gate

is chosen.

Aliasing can be reduced by increasing the PRF (by reducing the depth or expanding the velocity or Doppler scale), by increasing the angle of insonation, or by reducing the transducer frequency. Users should be-

come

familiar

with

the

appearance

of

aliasing on their system. Although aliasing complicates CD images, it does not usually limit image interpretation by experienced users. In

fact, aliasing the highest

age. that curs Aliasing a. b. Figure 16. Longitudinal CD images of a common carotid artery during peak systole demonstrate the effects of sensitivity to slow flow on color encoding. (a) In the high-flow mode, the peak velocity estimated from the image is 59 cm/sec. (b) Same image as a but with the low-flow option. The peak velocity is now estimated as 48 cm/sec, since more low velocity flow has been included in the estimate. Note that the diameter of flow has increased, presumably because sensitivity to flow adjacent to the vessel walls has increased. The low-flow
option also involves decreasing PRF, thus changing the color scale. Thus, there is much less

can be used to identify Doppler shifts in an imbe aware, at which dependent however, aliasing on scan problem ocpa-

One must the velocity is highly

rameters

and

angle

of insonation.
important

is a more however, of peak

for interpretation
forms, timation termine depicted

of spectral
as it may velocity.

waveprevent es-

In conclusion,

several

factors

deare of these

how flow phenomena in CD images. Some

are related
principles,

to fundamental
while others

Doppler
result Radiology from
#{149} 9

color

saturation 177

in the image.
#{149} Number

Volume

efforts

of manufacturers

or users

to

8.

Helmcke

F, Nanda

NC,

Hsiung planes.

MC,

et al.

19.

improve
ages. likely

the

appearance

of the

im9.

Color
gitation

Doppler
with

assessment
orthogonal

of mitral

regurCircula-

Reading CC, Charboneau Cooperberg PL. Color

Doppler clavian mirror-image artery. Radiology

and

JW, Allison spectral

of the 1990; 174:41-42.

JW,
sub-

Appreciation of these factors is to enhance the appropriate clinical use of CD imaging. #{149} Acknowledgments:
I thank the following individuals for substantive feedback during the preparation of this manuscript: Raymond Powis, PhD, Richard K. Johnson, PhD, Paul Magnin, PhD, Jeff Powers, PhD, Andrew Hayes, PARVT, Peter N. Burns, PhD, and Barry B. Goldberg, MD. I also thank Daniel A. Mer-

artifact

tion 1987; 75:175-183. Hoit B, Jones M, Eidbo E, Elias B, Sahn DJ. Sources of variability for Doppler color flow mapping imaging of regurgitant jets
in an animal model of mitral regurgita-

20.

10.

ton, BS, for technical

assistance.

11.

tion. J Am Coil Cardiol 1989; 13:16311636. Klewer SE, Lloyd TR, Goldberg SJ. In vivo relation between cineangiographic jet width and jet width imaged by colorcoded Doppler. Am J Cardiol 1989; 64:1399-1401. Stevenson JG. Two-dimensional color Doppler estimation of the severity of
atrioventricular valve frequency, regurgitation: im-

21.

Middleton WD, Melson GL. The carotid ghost: a color Doppler ultrasound mirror image artifact. J Ultrasound Med 1990; 9:S1. Daigle R. Quantitative aspects of color flow imaging. In: Nanda NC, ed. Textbook of color Doppler echocardiography.
Philadelphia: Lea Kossoff & Febiger, MB, Kossoff 1989; 283-

291.
22. Gill RW, G, Griffiths

New class biguity at short

173:272-275. 23. Middleton WD,

KA.

of pulsed Doppler ranges. Radiology

Foley in the WD, normal Lawson carotid

US am1989;
TL. bifur-

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October

1990