"People only see what they are prepared to see.

"
Ralph Waldo Emerson

NGUYN L V K THUT SIU M

DOPPLER
BS. NGUYN QUANG TRNG
(Last update 05/07/2011)

KHOA CHN ON HNH NH

02/08/2011 BNH VIN FV TP.HCM 1

 MC TIU BI GING

Hiu c hiu ng Doppler.

ng dng hiu ng Doppler vo trong siu m.
Nm c cc k thut, thao tc iu chnh trn my
khi thc hin siu m Doppler.
Phn tch c cc ph v m thanh thu c.

02/08/2011 2
 NI DUNG

Hiu ng Doppler.
Cc h thng Doppler.
Hin tng vt ngng.
K thut siu m Doppler.
Vi cas minh ho.
Phn tch ph Doppler.
Kt lun.

docteurtrong@yahoo.com,
doctortrong@yahoo.com,
trong1.nguyen@fvhospital.com

02/08/2011 3
 HIU NG DOPPLER
Hiu ng Doppler c tm ra vo nm 1842 bi nh ton hc v vt l hc
ngi o (Austrian mathematician and physicist) Christian Johann Doppler
(1803-1853).
Lc ng dng n gii thch hin tng lch mu sc ca cc ngi sao
ang chuyn ng: Khi ngi sao tin li gn qu t th nh sng ca n s
chuyn thnh mu xanh (tc l bc sng gim v tn s ca sng nh sng
tng ln). Ngc li, khi ngi sao i xa qu t th nh sng ca n chuyn
thnh mu (tc l bc sng tng ln v tn s gim xung).

02/08/2011 4
nh ngha: Hiu ng Doppler l s thay i tn s ca
sng khi c s dch chuyn tng quan gia ngun
pht sng v ngi quan st, tn s sng phn hi tng
ln khi ngun pht sng v/hoc ngi quan st tin li
gn nhau, tn s ny s gim xung trong trng hp
ngc li.

02/08/2011 5
 Mt hnh nh quen thuc l khi ta nghe ting ci
xe cp cu xa vi m trm (do tn s thp), khi xe
chy li gn th ta nghe m bng (do tn s cao).

02/08/2011 6
 Hoc l khi ta nghe ting tu ha ( ) t xa chy li
ri chy qua:

02/08/2011 7
 Nm 1959, Satomura (Nht) ln u tin ng dng
hiu ng Doppler vo Y hc nhm kho st tim-
mch.
Sau Pourcelot (Php) v Franklin (M) pht trin
tip k thut ny.
Khc vi siu m B-mode, my khng x l tn
hiu sng phn hi thnh hnh nh, m ch ghi
nhn s thay i tn s do hiu ng Doppler xy
ra khi chm sng siu m pht ra gp cc hng cu
chuyn ng trong mch mu ang tin li gn u
d hoc i xa u d.

02/08/2011 8
 Sng m gm c hai thnh phn:
tn s (frequency) v bin
(amplitude).
Tn s (f) sng m lin quan n
di bc sng (wavelength)
theo cng thc:
f = V(velocity) / (wavelength)
Vn tc sng m i qua hu ht
cc m trong c th vi vn tc
1.540m/giy. Do vy khi thay i
di bc sng th tn s sng
m cng thay i.
Bin biu hin cng ca
sng m.

02/08/2011 Arthur Fleischer, MD et al. Color Power Doppler Ultrasound. 1999 9

 Sng m c truyn i (transmitted-T) t mt u d
Doppler xung vi mt tn s hoc bc sng c nh.
Tn s ca sng m s khng thay i nu nh cc
cu trc m n gp trn ng i khng chuyn ng.

02/08/2011 Arthur Fleischer, MD et al. Color Power Doppler Ultrasound. 1999 10

 Chuyn ng ca cc t bo mu lm thay i tn s ca sng
phn hi tr v (reflected-R) u d. Nu chuyn ng ca
dng mu hng v u d th tn s sng phn hi s tng ln
v bc sng ngn li. Ngc li, nu dng mu chuyn ng
xa u d th tn s sng phn hi s gim v di bc sng
tng.

02/08/2011 Arthur Fleischer, MD et al. Color Power Doppler Ultrasound. 1999 11

 Do vy tn s ca sng truyn i v tr v khc nhau,
chng s lch pha vi nhau.
Hiu s ca hai tn s ny chnh l tn s Doppler
(F ).

02/08/2011 Arthur Fleischer, MD et al. Color Power Doppler Ultrasound. 1999 12

 - F: tn s Doppler.
- Fo: tn s ca sng pht i.
- Fr: tn s ca sng phn hi.
- v: vn tc ca dng mu.
- c : tc ca sng m truyn trong c th (#1540m/s).
- : gc gia chm tia siu m v mch mu.

W. Schaberle. Ultrasonography in Vascular Diseases. p1-27. 2005

02/08/2011 13
 T cng thc trn ta rt ra:
- Tn s Doppler F t l thun vi vn tc dng chy.
- F c tr s ln nht khi chm tia song song vi dng chy (cos =1).
Khi chm tia vung gc vi dng chy th s khng c tn hiu Doppler
(cos = 0).
- Vi u d pht vi tn s 2-8MHz th F thu c nm trong phm vi
tn s m tai ngi nghe c (50Hz-15KHz).
- Vn tc dng chy c tnh theo cng thc:

02/08/2011W. Schaberle. Ultrasonography in Vascular Diseases. p1-27. 2005 14

 CC H THNG DOPPLER

Doppler lin tc (continuous wave-CW).

Doppler xung (pulsed wave-PW).
Tn hiu Doppler xung.
Doppler mu (color Doppler).
Tn hiu Doppler mu.
Doppler nng lng (power Doppler).
Duplex v Triplex sonography.

02/08/2011 15
 CC H THNG DOPPLER
DOPPLER LIN TC
Doppler lin tc (continuous wave-CW) vi u d c
hai tinh th, mt c chc nng pht sng lin tc v
mt c chc nng nhn sng phn hi lin tc.

W. Schaberle. Ultrasonography in Vascular Diseases. p1-27. 2005

02/08/2011 16
 u im: Doppler lin tc o
c vn tc dng mu rt ln
(m iu ny thng thy
trong tnh trng bnh l).
Nhc im: N khng ghi
c tc ti 1 im xc
nh m n ch ghi c tc
trung bnh ca nhiu im
chuyn ng m chm sng
m pht ra gp trn ng i
ca n.

02/08/2011 17
02/08/2011 18
 Khi chm sng m xuyn
qua hai mch mu cnh
nhau (hai ng mch hoc
mt ng mch v mt
tnh mch) th tc ghi
c l tc trung bnh
ca cc tc hai mch
mu.

02/08/2011
C. M. Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005 19
 CC H THNG DOPPLER
DOPPLER XUNG
Pht sng dng xung c dng trong Doppler xung
(pulsed wave-PW) vi u d c mt tinh th va c
chc nng pht v nhn sng phn hi.

W. Schaberle. Ultrasonography in Vascular Diseases. p1-27. 2005

02/08/2011 20
 Sng m c pht i theo tng chui xung dc theo hng
qut ca u d, song ch nhng xung phn hi t v tr t
ca s (gate, sample volume) l c ghi nhn v x l.

02/08/2011 21
 TN HIU DOPPLER XUNG

Tn hiu Doppler thu nhn c th hin di dng

m thanh, dng ph v hnh nh.
Di dng m thanh, ta c th phn bit c dng
chy m du, lin tc ca tnh mch ( ); dng chy
pht gn, cch khong ca ng mch ( ); dng chy
pht ko di, th rp ca ng mch b hp ( ).

02/08/2011 22
 Ph Doppler gm c 3 thnh
phn:
Thi gian (time): c
m t theo trc X.
Tn s (frequency): c
m t theo trc Y.
Bin (amplitude):
c m t bng sng
(brightness) ca ph.

02/08/2011 Arthur Fleischer, MD et al. Color Power Doppler Ultrasound. 1999 23

 Ta phng i mt ph Doppler phn tch:
Hp xanh ch mt im thi gian trong chu k tim.
Nhng hp mu vng biu hin ln ca cc tn
s ring bit.

02/08/2011 Arthur Fleischer, MD et al. Color Power Doppler Ultrasound. 1999 24

 Vo mt thi im xc nh (hp hng) cc tn hiu Doppler c
tn s khc nhau c biu hin bng nhng v tr khc nhau
trn ph Doppler (cc mi tn).
Thng thng c mi 5-10ms, li c tn hiu Doppler c m
ho hnh thnh ph Doppler.

02/08/2011 Arthur Fleischer, MD et al. Color Power Doppler Ultrasound. 1999 25

 S khc nhau v bin biu hin bng sng trn
thang xm. Vi cng mt tn s, bin sng
cng cao th ph cng sng.

02/08/2011 Arthur Fleischer, MD et al. Color Power Doppler Ultrasound. 1999 26

 Theo qui c, khi dng mu i v pha u d th ta c ph
dng (pha trn trc X); ngc li, khi dng mu i xa u d
th ta c ph m (pha di trc X).

02/08/2011 27
Tuy vy, cn lu rng ph Doppler c th o ngc hon ton nu
ta n vo nt invert trn bn phm my siu m!
02/08/2011 28
 CC H THNG DOPPLER
DOPPLER MU (COLOR DOPPLER)

l tn hiu Doppler xung c m ha mu sc

ph ln hnh siu m hai chiu.
Trong khi Doppler xung ch c 1 v tr t ca s
(gate), th Doppler mu c rt nhiu v tr t ca
s k cn nhau trn vng kho st.

02/08/2011 29
 Thng tin Doppler thu nhn c t mi v tr t
ca s c phn tch xc nh hng dng chy
v tc trung bnh.
Nhng thng tin ny c chuyn i thnh tn
hiu mu chng ln hnh nh siu m hai chiu.

02/08/2011 30
 Tu theo cht lng ca my siu m, trn mi ng to
nh c khong 32 n 128 v tr ly mu (gate) hoc nhiu
hn, do vy c c thng tin chnh xc, ta hp mu
(color box, sample volume) va bao trm vng cn
kho st. Khi hp mu qu ln, my phi chia s kh
nng x l d liu, v do cht lng hnh nh v thng
tin thu c s km i.

02/08/2011 31
 Vi u d convex, vng xa u d, cc v tr ly mu (gate)
s tha ra do s phn k ca chm tia siu m, do vy s c
nhng v tr khng c thng tin Doppler. khc phc hin
tng ny my s lm php tnh trung bnh ca 2 v tr ly mu
cnh nhau to thng tin Doppler cho vng khuyt chen
gia.

02/08/2011 32
 Dng chy hng v u d c m ha mu ;
ngc li, chy xa u d c m ha mu xanh.

02/08/2011 33
 Tn hiu mu thu c s chng ln hnh siu m 2D, cho
ra hnh siu m mu.

02/08/2011 34
Tuy vy, cn lu rng mu sc c m ha ny c th o ngc
hon ton nu ta n vo nt invert trn bn phm my siu m!
02/08/2011 35
02/08/2011 36
 TN HIU DOPPLER MU
Vi dng chy lp th vn tc kh ng nht, trong khi vi dng
chy cun xoy th c nhiu vn tc v hng chy khc nhau; do
nu ch m ha hai mu xanh- th s b st thng tin m tn
hiu Doppler em li. khc phc iu ny ngi ta m ha thm
cc mu th hin bng s di y (thm mu vng v mu lc
lam):

02/08/2011 37
 V Doppler mu ch s dng tn s trung bnh, n c
th biu hin c hng (nh mu - color) v tn s
trung bnh (nh sc mu - hue) ca dng chy trong
cng mt vung (pixel).

02/08/2011 38
Arthur Fleischer,M.D et al. Color Power Doppler Ultrasound.1999.
 V vn tc trung bnh
gia dng (B) lun
lun cao hn vn tc
cnh thnh mch (A
v C), sc mu (hue)
gia dng sng hn
hai bn tng ng vi
vn tc hoc tn s
trung bnh cao hn.

02/08/2011 39
 CC H THNG DOPPLER
DOPPLER NNG LNG (POWER DOPPLER)

Doppler mu nh gi tt s hin din v chiu ca

dng chy, tuy vy n khng th nh gi c cc
mch mu nh li ti (mao mch). Do khng th
nh gi tt s ti mu ti cc m.
Doppler nng lng ra i, ch kho st ln ca
tn hiu Doppler m khng quan tm n chiu ca
dng chy.

02/08/2011 40
 Vi Doppler mu, trong hp mu (color box,
sample volume) hin din ng thi cc vector vn
tc ngc hng nhau, do vy gi tr trung bnh
ca vn tc s nh i, thm ch b trit tiu.
Vi Doppler nng lng th hon ton khng ph
thuc vo cc vector vn tc, do vy n c nhy
cao hn nhiu so vi Doppler mu, ng thi n
cng d c so nh do chuyn ng hn.

02/08/2011 41
 Khc vi Doppler xung th hin tt c cc bin ,
Doppler nng lng ch th hin bin trung bnh
(MEAN amplitude) v cho mu hng trn hnh thu
c bt k dng mu n hay i xa u d.

02/08/2011 Arthur Fleischer,M.D et al. Color Power Doppler Ultrasound.1999. 42

 Vi Doppler nng lng, mu c m ha biu hin c
hay khng c dng chy. N khng cho bit hng ca dng
chy.

02/08/2011 43
02/08/2011 44
 CC H THNG DOPPLER
DUPLEX SONOGRAPHY
S kt hp hnh nh siu m hai chiu (cung cp thng tin
v cu trc gii phu, v tr t ca s, gc ) v Doppler
xung (cung cp thng tin v dng chy) c gi l Duplex
sonography.

02/08/2011 45
 CC H THNG DOPPLER
TRIPLEX SONOGRAPHY
S kt hp hnh nh siu m hai chiu (cung cp thng tin
v cu trc gii phu, v tr t ca s, gc ), Doppler mu
v Doppler xung (cung cp thng tin v dng chy) c gi
l Triplex sonography.

02/08/2011 46
 HIN TNG VT NGNG
(ALIASING PHENOMENON)

Trong Doppler xung c mt yu t gi l tn s lp

li xung (Pulse Repetition Frequency-PRF):
PRF=C/2d
+C: Tc sng siu m trong c th.
+d: Chiu su ca mch mu.
Nh vy PRF l s ln mi giy m chm siu m
i-v gia u d v mch mu.

02/08/2011 47
 PRF c tnh bng kHz.
Cc tn hiu Doppler xung ch c thu nhn tt khi
c tn s bng hoc thp hn PRF/2. Tn s gii hn
ny gi l tn s NYQUIST.
Khi tn hiu Doppler xung c tn s vt tn s
NYQUIST th s xy ra hin tng vt ngng.
Lc ny ph Doppler xung s b ct ct, Doppler mu
s xut hin thm sc vng ngoi hai mu xanh - .

02/08/2011 48
02/08/2011 49
Joseph A.Kisslo,MD. Basic Echo-Doppler
 Aliasing ph Aliasing mu

02/08/2011 50
 Hin tng ny c gii thch nh sau: V nh ta c 1 bnh
xe, trn bnh xe c nh du 1 im. Ta quay bnh xe theo
chiu kim ng h vi tc vng/giy.
Nu ta ghi nhn hnh nh mt ln mi giy (tng ng vi
tn s lp li xung PRF) th im nh du s chuyn ng
theo chiu kim ng h, cch nhau 900 .

02/08/2011 51
 Nu ta ghi nhn hnh nh vi tn sut chm hn, ch mt ln
cho mi 3 giy (tng ng vi tn s lp li xung PRF)
th s c hin tng l xy ra: Trong lc bnh xe quay theo
chiu kim ng h th im nh du li chuyn ng ngc
chiu kim ng h, cch nhau 900.

02/08/2011 52
 K THUT SIU M DOPPLER

c mt kt qu siu m Doppler ng tin cy, cc

BS lm siu m Doppler cn phi bit cch iu
chnh cc nt chc nng ca my cho ra kt qu
tt nht.
Ngoi ra, cht lng ca my cng l im ng lu
v n nh hng khng t n kt qu siu m.
Tuy vy, ta cn phi nm vng k thut siu m
Doppler cho ra kt qu tt nht.

02/08/2011 53
 Cc k thut bao gm:
K thut trnh hin tng vt ngng.
iu chnh thang tc mu.
iu chnh lc thnh.
iu chnh gc .
iu chnh kch thc v hng ca s.
iu chnh kch thc v hng ca hp mu.
iu chnh gain ph v gain mu.

02/08/2011 54
 K THUT TRNH HIN TNG VT NGNG
1. Chuyn dch ng nn (baseline) ln trn hoc xung
di ty thuc ph thu c.
2. Tng PRF: my thu tn hiu nhiu ln trn ng i v ca
sng m.
3. Gim F bng cch gim tn s u d (vi u d a tn
s), i u d c tn s thp hn.

02/08/2011 55
02/08/2011 56
 Chnh baseline trnh
aliasing ph.

Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US: Application to Hepatic
02/08/2011 57
Sonography. RadioGraphics 2004;24:657-675
 Chnh color baseline trnh
aliasing mu.

Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US: Application to Hepatic
02/08/2011 58
Sonography. RadioGraphics 2004;24:657-675
02/08/2011 59
 PRF=3731 Hz

PRF=14286 Hz

Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US: Application to Hepatic
02/08/2011 60
Sonography. RadioGraphics 2004;24:657-675
02/08/2011 61
 PRF = 04 kHz PRF = 10 kHz

02/08/2011 62
 PRF = 04 kHz PRF = 06 kHz, di chuyn ng nn

02/08/2011 63
02/08/2011 64
 PRF qu cao: b st tn hiu
PRF qu thp: Aliasing PRF ng
mu cnh thnh mch

Abigail Thrush et al. Peripheral Vascular Ultrasound How, Why and When. 2nd Edi. 2005
02/08/2011 65
 M chy sau, on xa,
PRF=2500 Hz

PRF c iu chnh gim

xung 1000 Hz

Doppler xung cho thy dng chy

c PSV rt thp, 10,3 cm/s
Abigail Thrush et al. Peripheral Vascular Ultrasound How, Why and When. 2nd Edi. 2005
02/08/2011 66
 u d 7-7,5 MHz u d 2,8-3,5 MHz

02/08/2011 67
Ngi ta da vo hin tng vt ngng nhn bit ch hp ca mch mu !

02/08/2011 68
 IU CHNH THANG TC MU (color velocity scale)
- Nu thang tc mu t thp hn vn tc trung bnh ca
dng mu th ta khng th phn bit c u l dng bnh
thng u l dng cun xoy tc cao.
- Nu thang tc mu t cao hn vn tc trung bnh ca
dng mu th hin tng aliasing c th bin mt, lc ta s b
st ch hp.
- ch mch mu gn tc tc dng mu rt thp, lc ny ta
cn gim thang tc mu xung tht thp (c my c th
gim n 1 cm/s) trnh dng tnh gi ca tc mch. Nu vn
khng thy c dng chy th cn phi lm thm CTA, MRA
hoc Angiography trc khi kt lun tc mch hon ton.
- PRF v thang tc mu c lin h mt thit vi nhau, ta tng
tc mu bng cch tng PRF v ngc li.
02/08/2011 69
02/08/2011 70
02/08/2011 71
 Thang tc mu - 69.2cm/s +
69.2cm/s: mt ph mu (qu cao).

Thang tc mu - 2.3cm/s +
2.3cm/s: Aliasing (qu thp).

Thang tc mu -30.7cm/s +
30.7cm/s (chnh ng).
02/08/2011 72
Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US: Application to Hepatic
Sonography. RadioGraphics 2004;24:657-675
 Huyt khi tnh mch ca ?
(cc u mi tn)

Sau khi iu chnh thang tc

mu t 20cm/s xung 7cm/s, ta
thy xut hin ph mu trong
lng TMC (cc u mi tn)
02/08/2011 73
 Chnh thang tc mu Chnh thang tc mu Chnh thang tc mu
qu cao (maximum va phi (maximum qu thp (maximum
velocity=77cm/s) velocity=32cm/s) velocity=08cm/s)

Paul L Allan et al. Clinical Doppler Ultrasound. 2nd Edi. 2006

02/08/2011 74
02/08/2011 75
02/08/2011 76
02/08/2011 H.R.Tahmasebpour et al. Sonographic Examination of the Carotid Arteries. 77
Radiographics.2005;25:1561-1575.
 Thang tc mu chnh qu thp Thang tc mu chnh qu cao

Thang tc mu chnh ng
02/08/2011 78
 Thang tc mu thp thy c
Thang tc mu cao b st dng chy hp, ngon ngoo
dng chy vn tc thp ? Chn on chnh xc l gn tc ch
khng phi l tc hon ton.

H.R.Tahmasebpour et al. Sonographic Examination of the Carotid Arteries.

02/08/2011 Radiographics.2005;25:1561-1575. 79
02/08/2011 80
 IU CHNH LC THNH (wall filter):
- Ta dng chc nng lc thnh (wall filter) nhm mc ch loi b
tn hiu tn s thp do thnh mch chuyn ng to thnh. Th
nhng khi lc thnh t qu cao, dng chy gn thnh c tc
thp s b b st.
- lc thnh c biu th vng gia thang tc mu.
- Trn my, lc thnh kt hp cng vi PRF trn mt nt chc
nng. Khi ta tng PRF, lc thnh tng theo v ngc li.
- cc my tt hn, ngoi nt chc nng PRF, lc thnh cn
c iu chnh ring bit:
+Vi cc my ny, khi ta gim PRF th lc thnh gim theo
v ngc li.
+ Nhng khi ta chn iu chnh ring lc thnh th PRF
khng b nh hng.
02/08/2011 81
 My c nt chc nng chung cho PRF v lc thnh, ta xoay nt theo chiu
kim ng h nu mun iu chnh tng PRF v wall filter v ngc li.

02/08/2011 82
 iu chnh PRF t 3.4kHz xung 1,7kHz, vn tc mu gim t 25cm/s xung
12cm/s, ng thi lc thnh cng gim t 262Hz xung cn 135Hz.

02/08/2011 83
 My c nt chc nng PRF v nt chc nng ring cho lc thnh
My ang hin th nt o chc nng PRF, ta xoay nt theo chiu
kim ng h nu mun iu chnh tng PRF v ngc li.
02/08/2011 84
 iu chnh ring lc thnh, ta nhn nt iu chnh, my s chuyn sang
iu chnh lc thnh (wall filter). Ta xoay nt theo chiu kim ng h nu
mun iu chnh tng v ngc li.

02/08/2011 85
 iu chnh lc thnh (wall filter) t 790Hz xung 262Hz,
PRF v vn tc mu khng thay i.

02/08/2011 86
 Ph hp van MC, wall filter c iu chnh
(mi tn) loi b cc tn hiu c vn tc thp.

02/08/2011 87
Wall filter t qu cao mt tn hiu Gim wall filter khng mt tn
mu cnh thnh mch hiu mu cnh thnh mch

02/08/2011 88
 Ph o dng TMC do tng p
lc TMC. Huyt khi TMC (cc
mi tn) ?

Gim vn tc mu, gim lc

thnh xung thp xut hin
dng chy trong TMC khng
c huyt khi.

02/08/2011 89
 IU CHNH GC
tnh chnh xc vn tc dng chy th gc lun lun < 600
( sai s chp nhn c).

02/08/2011 90
 Hnh di y minh ha tm quan trng ca vic ly gc :
c bit vn tc thc s ca dng mu qua van MC l 2m/s.
Khi gc = 100, vn tc o c l 1,97m/s.
Khi gc = 300, vn tc o c l 1,73m/s.
Khi gc = 600, vn tc o c l 1,00m/s.

02/08/2011 91
Joseph A.Kisslo,MD. Basic Echo-Doppler
02/08/2011 92
02/08/2011 93
 IU CHNH KCH THC V HNG CA CA S
- Ca s qu nh s b st tn hiu Doppler.
- Ca s ng:
+ Vi kho st h tnh mch, cc ng mch nh: ca s ly ht
ng knh mch mu (c gng thu nhn ti a tn hiu dng chy).
+ Vi kho st cc ng mch ln: ca s l tng chim 1/3
ng knh mch mu v t 1/3 gia ca lng mch (loi b tn
hiu dng chy thp hai bn thnh mch).
+ Ring vi cung rn, ca s c t bao trm c M ln TM
rn: v trong mt s tnh trng bnh l iu ny gip ta pht hin
ph TM rn p.
- chn on hp mch mu ta phi chnh hng ca ca s
song song vi hng ca dng chy (ch khng phi song song
vi thnh mch) cho tr s PSV v EDV ng nht. Tuy nhin,
vi kho st Doppler trong sn-ph khoa th ta thng quan tm
n tr s RI, tr s ny khng b nh hng bi hng ca ca
s02/08/2011
cho nn ta khng cn iu chnh. 94
 A. Colignon et al. Manuel de Diagnostic Echo-Doppler des Thromboses Veineuses Profondes. 199495
02/08/2011
 Ca s l tng chim 1/3 ng knh mch
mu ln v t 1/3 gia ca lng mch.
02/08/2011 96
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 Vn tc dng chy trc khi
chnh gc: 18cm/s

Chnh gc qu thp (300)

vn tc dng chy thp
hn so vi thc t.

Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US: Application to Hepatic
02/08/2011 101
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 Vn tc dng chy trc khi
chnh gc: 18cm/s

Chnh gc qu cao (700)

vn tc dng chy cao
hn so vi thc t.
Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US: Application to Hepatic
02/08/2011 102
Sonography. RadioGraphics 2004;24:657-675
 Vn tc dng chy trc khi
chnh gc: 18cm/s

Vn tc dng chy sau khi

chnh gc ng (song song vi
dng chy): 29,3cm/s

Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US: Application to Hepatic
02/08/2011 103
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Gc ca ca s khng song song vi Gc ca ca s song song vi dng
dng chy, PSV=356cm/s (sai) chy, PSV=155cm/s (ng)

02/08/2011 104
 Gc ca ca s song song vi thnh Gc ca ca s song song vi dng
mch, PSV=198cm/s (sai). chy, PSV=376cm/s (ng).

Paul L Allan et al. Clinical Doppler Ultrasound. 2nd Edi. 2006

02/08/2011 105
SV: sample volume (ca s). Gc ca Gc ca SV song song vi dng chy
SV song song vi thnh mch cho kt cho kt qu PSV ca ICA l 161cm/s,
qu PSV ca ICA l 229cm/s, tng tng ng vi hp > 50-69% (chnh
ng vi hp > 70% (khng chnh xc). xc).

H.R.Tahmasebpour et al. Sonographic Examination of the Carotid Arteries.

02/08/2011 Radiographics.2005;25:1561-1575. 106
 SV t ng v tr (A) trn mt M
cnh trong ngon ngoo.
H.R.Tahmasebpour et al. Sonographic Examination of the Carotid Arteries.
02/08/2011 Radiographics.2005;25:1561-1575. 107
02/08/2011 108
 IU CHNH V TR, KCH THC V HNG CNH BN
CA HP MU
- Hp mu t cng su cng d b hin tng vt ngng, do vy
c gng thay i hng tip cn kt hp vi xoay tr bnh nhn,
sao cho vng cn kho st khng qu xa u d.
- Hp mu cng ln th hnh nh thu c c phn gii dc cng
km, do vy chnh hp mu va bao trm vng cn kho st.
- Chnh hng cnh bn ca hp mu to gc < 600 so vi
hng ca dng chy (v hng ca chm tia siu m chnh l
hng cnh bn ca hp mu).

02/08/2011 109
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02/08/2011 111
 Hp mu qu ln Hp mu va

Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US: Application to Hepatic
02/08/2011 112
Sonography. RadioGraphics 2004;24:657-675
 Hng cnh bn ca hp mu vung gc vi dng chy
gc = 900 Hu nh khng c tn hiu mu.

02/08/2011 M. A. Mansour et al. Vascular Diagnosis. 2005. Elservier 113

02/08/2011 114
02/08/2011 115
 l gc nhn c to thnh bi hng ca dng chy giao nhau vi
hng cnh bn ca hp mu.

hng cnh bn hp mu
hng cnh bn hp mu

hng dng chy hng dng chy

Hng cnh bn ca hp mu gn nh
vung gc vi dng chy Hng cnh bn ca hp mu to mt
Khng ng. (Lu rng mu ca gc < 600 vi dng chy ng.
dng chy cng biu th sai).

02/08/2011 116
 Hng cnh bn ca hp mu Hng cnh bn ca hp mu
(cng chnh l hng ca chm tia) (cng chnh l hng ca chm tia)
gn nh vung gc vi dng chy to mt gc < 600 vi dng chy
Khng ng. ng.

02/08/2011 117
 Hng cnh bn ca hp mu
(cng chnh l hng ca chm tia)
vung gc vi dng chy
Khng ng.

Hng cnh bn ca hp mu
(cng chnh l hng ca chm tia)
to mt gc < 600 vi dng chy
ng.
02/08/2011 H.R.Tahmasebpour et al. Sonographic Examination of the Carotid Arteries. 118
Radiographics.2005;25:1561-1575.
Nu chnh hng cnh bn ca hp mu sai, th hnh nh thu c s
c ph mu khng chnh xc, iu ny dn n nhn nh sai v
hng ca dng chy (Khi nhn nh hng ca dng chy lun lun
phi so snh vi chiu hng trn thang tc mu).
Vi nhng mch mu chy gn nh song song vi mt da, th ta n
nh u d mt pha cho mch mu khng cn song song vi
mt da na (vi hai hnh trn, u d n nh pha u bnh nhn).

Khi kho st trn mt on mch mu, vic iu chnh hng cnh

bn ca hp mu phi linh hot sao cho to mt gc nh nht so vi
hng ca dng chy.

02/08/2011 119
 Cn phi nh gi ng hng ca dng chy, bi v trong mt s
tnh trng bnh l, dng chy c th b o ngc (retrograde flow).
Vic nh gi ng hng ca dng chy gip ch rt nhiu trong
bin lun chn on.

Dng chy thun dng (antegrade flow) l dng chy bnh thng
c hng t tim ra ngoi vi.
Dng chy o ngc (retrograde flow) l dng chy c hng t
ngoi vi v trung tm, ch gp trong cc tnh trng bnh l.

02/08/2011 120
 IU CHNH GAIN PH V GAIN MU
Nu gain ph hoc gain mu qu thp s b st tn hiu, nu
qu cao s b hin tng soi gng (Doppler ph) hoc lem
mu (Doppler mu).

02/08/2011 121
02/08/2011 122
 Ph h van 3 l, gain qu thp Ph van MC, gain qu cao

02/08/2011 123
 Chnh gain ph

Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US: Application to Hepatic
02/08/2011 124
Sonography. RadioGraphics 2004;24:657-675
 Nhng khi gain ph c chnh qu cao s xut
hin hnh nh soi gng qua ng nn.

02/08/2011 125
02/08/2011 126
 Gain mu qu cao: lem mu

Gain mu qu thp: mt tn hiu, cho

hnh nh gi huyt khi trong TM ca.

Gain mu va : tn hiu trm u

trong lng TM ca.
Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US: Application to Hepatic
02/08/2011 127
Sonography. RadioGraphics 2004;24:657-675
Gain mu qu cao: khng thy ch hp Gain mu va : pht hin mng x
v mu b lem che khut mng x va. va v ch hp.

H.R.Tahmasebpour et al. Sonographic Examination of the Carotid Arteries.

02/08/2011 Radiographics.2005;25:1561-1575. 128
 nh v mch mu, ta lun lun bt u bng lt ct ngang
qua trc ca mch mu. L tng l mch mu ng gia
mn hnh (midline).
T lt ct ngang ta xoay u d theo chiu kim ng h ly
lt ct dc.
Nu mch mu chy song song vi mt da, th ta n nh cnh
bn u d mch mu khng cn song song vi mt da.

02/08/2011 129
 PHN TCH PH DOPPLER

Ph Doppler phn nh huyt ng ca dng chy.

Th tm thu, do lc co bp ca qu tim, vn tc dng chy
tng cao. o vn tc ti a ca dng mu t c,
ngi ta dng khi nim vn tc nh tm thu (peak
systolic velocity-PSV).
Th tm trng, tuy rng tim khng co bp, nhng dng
chy vn c duy tr do s co bp ca thnh mch, dng
chy c vn tc thp hn. nh gi dng chy trong th
tm trng, ngi ta o vn tc cui tm trng (end
diastolic velocity).

02/08/2011 W. Schaberle. Ultrasonography in Vascular Diseases. 2005 130

 Ngi ta tnh ch s khng (resistance index) nh gi
khng lc ca mch mu.
RI = (A-B)/A

02/08/2011 W. Schaberle. Ultrasonography in Vascular Diseases. 2005 131

 Dng chy tr khng thp (low-resistance flow):
M cung cp mu cho cc c quan (trng yu) trong c th
(M gan, lch, thn, M cnh trong, M ct sng) l
nhng dng chy tr khng thp vi ph gim dn t nh
tm thu ko di sut k tm trng.

02/08/2011 132
W. Schaberle. Ultrasonography in Vascular Diseases. 2005
 Dng chy tr khng cao (high-resistance flow):
M cung cp mu cho cc chi l nhng dng chy tr
khng cao vi ph o ngc tin tm trng, dng chy
thp gia tm trng v khng c dng chy cui tm
trng, to nn sng 3 pha.

02/08/2011 133
W. Schaberle. Ultrasonography in Vascular Diseases. 2005
 Da vo phng trnh lin tc, ta suy ra rng: khi din tch
dng chy cng gim th vn tc dng chy cng tng

02/08/2011 W. Schaberle. Ultrasonography in Vascular Diseases. 2005 134

 hiu c cc dng chy ta cn phi phn bit dng chy lp
(laminar flow) v dng chy cun xoy (turbulent flow).
Dng chy lp thy c cc mch mu c vch song song v
nhn (smooth), nh vy cc hng cu cng mt vng s chuyn
ng vi cng mt vn tc v cng hng.
Tuy vy, do c s ma st vi thnh mch, dng chy cnh thnh
mch lun lun hi thp hn dng chy trung tm.
Phn ln dng chy ca h tim-mch (bao gm tim v cc mch
mu ln) l dng chy lp v him khi c vn tc > 1,5m/s.

02/08/2011 135
 Dng chy cun xoy (turbulent flow) xut hin khi c s tc
nghn ngn chn dng chy lp. iu ny khin cho cc hng
cu chuyn ng hn lon, khng cng hng v to nn v s
dng xoy. Nu tc nghn nng, hng cu c th chuyn ng
vi vn tc 7m/s.

02/08/2011 136
 dng chy khng b hp, ta c dng chy lp vi vn tc kh ng u. iu
ny khin cho ph Doppler c tn s kh ng u, to nn ng vin ph
(spectral envelope) mng, cho hnh nh ph trng chn hay cn gi l c ca
s ph (spectral window)
02/08/2011 137
 dng chy khng b hp, ta c dng chy lp vi vn tc kh ng u.
iu ny khin cho ph Doppler c tn s kh ng u, cho hnh nh ph
trng chn hay cn gi l c ca s ph (cc mi tn)
02/08/2011 138
 dng chy b hp nh, ta c dng chy ri vi vn tc khng ng u.
iu ny khin cho ph Doppler c tn s khng ng u, to nn ng
vin ph (spectral envelope) dy, lm gim hnh nh ph trng chn
(gim kch thc ca s ph).

02/08/2011 139
 dng chy b hp va v nng, ta c dng chy ri vi vn tc rt khng
ng u. iu ny khin cho ph Doppler c tn s rt khng ng u, to
nn ng vin ph (spectral envelope) rt dy, lm mt hnh nh ph trng
chn (mt ca s ph), ng thi PSV tng cao.
02/08/2011 140
 dng chy b hp va v nng, ta c dng chy ri vi vn tc rt khng
ng u. iu ny khin cho ph Doppler c tn s rt khng ng u, to
nn ng vin ph (spectral envelope) rt dy, lm mt hnh nh ph trng
chn (mt ca s ph), ng thi PSV tng cao.
02/08/2011 141
 Khi t ca s ngay sau ch hp nng, ta ng thi ly c ph Doppler c b
trn hnh rng ca biu hin ca dng chy cun xoy (turbulent) (cc mi tn),
ng thi cng xut hin ph o ngc dng chy (flow reversal) (mi tn ln).

02/08/2011 142
02/08/2011 143
 S biu din s tiu hao nng lng ca
dng chy khi i qua mt ch hp.

02/08/2011 144
 S biu din cho thy vn tc dng chy tng ln khi i qua ch hp.
Nhng khi dng chy qu hp th khi qua c ch hp, vn tc s nhanh
chng gim xung v tiu hao qu nhiu nng lng.
02/08/2011 145
 Ph Doppler bnh thng trc hp (1), tng cao PSV khi qua ch hp
(2), ngay sau ch hp, PSV vn cn cao ng thi xut hin ph o
ngc (flow reversal) (3), h lu ch hp PSV thp hn trc hp v b
tiu hao nng lng nhiu khi i qua ch hp (4,5).
02/08/2011 146
 Ngay trc hp

Ngay sau hp: PSV tng cao, xut hin

dng cun xoy (cc mi tn) v ph
o ngc (flow reversal-mi tn ln).

Sau hp: PSV thp hn trc hp

02/08/2011 v b tiu hao nng lng 147
 PH TARDUS-PARVUS ?

02/08/2011 148
 PH TARDUS-PARVUS

Vi dng chy b hp nng thng lu, ta c ph

tardus parvus (ph mch chm) h lu dng
chy. Ph ny cn gp dng chy do tun hon
bng h hnh thnh.
c trng ca ph ny l thi gian gia tc (AT
acceleration time) ko di, PSV thp v trn. Ta cn
nhn bit c dng sng ny trnh b st chn
on.
Ph ny c th bt gp bt c ng mch no trong
c th. Nhng d hnh dung, ta ly trng hp hp
M thn lm v d:

02/08/2011 149
 PH TARDUS-PARVUS

Hp > 75% vi tng PSV > 150cm/s, AT (acceleration time thi gian gia tc) >
0,07s on gn M thn (P) v ph tardus-parvus trong nhu m thn (P) vi AT
ko di, PSV thp v trn.

02/08/2011 C.M.Rumack et al. Diagnostic Ultrasound. 3rdEdition.2005 150

 Ph bnh thng M gian thu thn Ph tardus-parvus M gian thu thn

02/08/2011 151
 So snh ph M cnh chung, cnh trong bnh thng v
ph tardus-parvus h lu ch hp.

02/08/2011 152
Ph bnh thng M cnh chung (P) ?

Sng tardus-parvus MCC (P) Angiography: Hp nng thn M

cnh u.

02/08/2011 153
 Ph tardus-parvus do tun hon bng h hnh thnh

02/08/2011 154
 KT LUN

c th lm tt siu m Doppler th vic u tin l

phi hiu c nguyn l ca siu m Doppler. N
c xem nh nn mng ca ngi nh.
Vic nm vng nguyn l ny cng gip ta bit cch
iu chnh cc yu t k thut sao cho t c kt
qu chnh xc nht.
Phi bit phn tch ph Doppler, t ph Doppler ta c
th chn on c cc thay i huyt ng ca dng
chy.

02/08/2011 155
 TI LIU THAM KHO
W. Schaberle. Ultrasonography in Vascular Diseases. Springer 2010
Abigail Thrush et al. Peripheral Vascular Ultrasound How, Why and When. 2nd
Edition. Elsevier 2005
M. A. Mansour et al. Vascular Diagnosis. 2nd Edition. Elsevier 2005
Ali F. AbuRhama et al. Noninvasive Vascular Diagnosis-A Practical Guide to
Therapy. 2nd Edition. Springer 2007
Paul L Allan et al. Clinical Doppler Ultrasound. 2nd Edition. 2006
Joseph F. Polak. Peripheral Vascular Sonography. 1992
Carol A. Crebs et al. Color Doppler. 2001
D. Eugene Strandness. Duplex Scanning in Vascular Disorders, 3rd Edition.
Lippincott Williams & Wilkins 2002
C. M. Rumack et al. Diagnostic Ultrasound. 3rd Edition. 2005
Jonathan B. Kruskal, MD, PhD et al. Optimizing Doppler and Color Flow US:
Application to Hepatic Sonography. RadioGraphics 2004;24:657-675
H.R.Tahmasebpour et al. Sonographic Examination of the Carotid Arteries.
Radiographics.2005;25:1561-1575.
Joseph A.Kisslo. Basic Echo-Doppler

02/08/2011 156