8/23/2019

Ultrasound Training Course; Basics and Beyond Basics Outlines

Dr. Hidayatullah Hamidi
A. Overview

B. Basic Physics
1 C. Type of Ultrasound Display

Ultrasonography D. Transducers

E. Artifact
General Issues & Basics Physics

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The Story Of Diagnosing Disease A

• Clinical History

• Physical examination

• Preliminary laboratory tests

• Radiological examinations (X-ray, USG, CT, MRI, Nuclear imaging)

• Biopsy and Histopathology Overview

• Observation and Follow up Definition
“A diagnostic imaging technique utilizing reflected high frequency
sound waves to delineate the internal body structures”
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Clinical Applications Advantages & Limitations

• Cardiovascular • Scrotum Advantages Limitations

• Hepatobiliary • Eye • No ionizing radiation • Highly operator dependent

• Spleen, pancreas, adrenals • Musculoskeletal (Both knowledge and skill)
• Patient-friendly
• Urinary system • Breast • Cannot penetrate gas & bone
• Availability & Low cost
• Obstetrics • Thyroid • Limited in fatty patients
• Portability
• Gynecology • Neck masses
• Real time exam
• Bowel and abdominal cavity • Interventional
• Possibility of repeated exams

• Good for children and in obstetrics

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B Sound Wave Propagation

Physical principle Effect on image
• Sound needs a medium for movement Ultrasound Gel:
• The closer the molecules of medium, • Fills space between probe & patient
the faster the move of sound in it Lungs & bowel (air):
• Gas (Slowest) → Fluid → So ssue → • Hides structures behind them
Bone (Highest) • Needs a window: soft-tissue/fluid
• Sound is constant for each medium Bones
• Sound speed in soft tissue: 1540 m/s • Faster speed of sound that USG
Basic Physics cannot accommodate

• Audible sound: 20- 20000 Hz

• Ultrasound: 1 to 30 MHz

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Pulse–Echo Principle Beam Angle to Interface

Physical principle
• Electrical pulse strikes crystal & produces
a sound beam
• Sound beam propagates through tissues
• Echoes arising from structures are
reflected back to crystal
• Cristal generates electrical impulse
comparable to strength of returning echo
Effect on image Physical principle Effect on image
• USG imaging shows echoes in varying • Strength of returning echo is related to • Try to image a structure from different
levels of grayness, depending on the angle that beam strikes acoustic interface angles to produce best representation
strength of interface. • More nearly perpendicular the beam, the
stronger the returning echo
• Smooth interfaces at right angles to
beam are known as specular reflectors
• Echoes reflected at other angles are
known as scatter

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Tissue Acoustic Impedance (AI) Absorption and Scatter

Physical principle Effect on image Physical principle Effect on image
• Returning echo’s strength also depends • Structures of differing AI (gallbladder • As much of sound beam is absorbed or • Increased absorption and scatter
on differences in AI between body tissues and liver) are much easier to scattered as it travels through body, it prevent one from seeing the distal
• AI relates to tissue density. distinguish from one another than are undergoes progressive weakening portions of a structure.
structures of similar acoustic texture (attenuation). • In obese patients, diaphragm is often
• The greater the difference in density (kidney and liver)
between two structures, the stronger the not visible beyond fatty liver
returning interface echoes defining the • Fibroids may absorb so much sound
boundaries between two structures that their posterior borders may be
difficult to define.

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Transducer Frequency Gain

Physical principle
• Transducers come in many different
frequencies (2.5, 5, 7, 10… MHz)
• Increasing the frequency improves
resolution but decreases penetration.
• Decreasing the frequency increases
penetration but diminishes resolution.
Effect on image • Controls the degree of brightness of the image
• Choose transducer according to organ
being examined & patient’s size
• Superficial structure; higher frequency
• Deeper the structure: lower frequency
• Pediatrics, Neck, breast, scrotum…

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C Type of Ultrasound Display

Amplitude Modulation (A-Mode)
• The most basic form of diagnostic ultrasound, Currently not used
• Single beam of ultrasound is analyzed
• May help to differentiate a cystic lesion from a solid
Brightness Mode (B-Mode)
• Basis of all real-time scanners today
Motion Mode (M-Mode)
Type of Ultrasound Display
• Series of B-mode dots, graphing the motion of mobile structures
• Used in echocardiography
Real-time B-Mode
• Provides a cinematic view of area being evaluated
• All modern imaging systems use a real-time approach
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D Components Of a Transducer
Transducer consists of five main components:
1. Crystal: Piezoelectric material converting electrical voltage to acoustic energy and vise versa
2. Matching layers: provides acoustic connection to skin
3. Damping material: decreases secondary reverberations of crystal with returning signals
4. Transducer case: housing for the components
5. Electric cable: Electrical wires exciting transducer elements and receiving returned impulses

Transducers (probes)

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Sector transducer Linear transducer

• Higher frequency with high resolution in the near field and a larger superficial field of view
• Single large piezoelectric element generates and receive ultrasound pulses.
• Produces real time grayscale image, but not so fast to produce real-time color Doppler image

Advantage Disadvantage Advantage Disadvantage

• Areas with small access windows • The wedge-shaped image gives you a • Large field of view in superficial areas • Needs larger window
(intercostal, through fontanelle) limited near field of view • Excellent for small parts, peripheral • No deep penetration
vascular studies…
• High resolution

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Convex transducer Other Transducers

Used for majority of deep organs in the abdomen and pelvis
Intraluminal

• Endovaginal
Advantage Disadvantage
• Endorectal
• Larger field of view, good for large • Needs larger window
structures • May acquire artifacts along sides of • Endoesophageal
• Good near- field resolution image due to poor contact

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E Importance

• Essential to recognize to maximize available information and to avoid diagnostic errors

• Some provide useful diagnostic information: (shadowing and enhancement)

Image appearance that do not accurately represent a structure • Others are undesirable and cause loss of information (reverberation, refraction…)

• Misleading appearances; if unrecognized or misinterpreted, leads to incorrect diagnosis

Artifacts • Some can be reduced or avoided by handling of probe and adjustment of control settings

• Acoustic Shadowing • Comet Tail

• Acoustic Enhancement • Ring down
• Edge Shadowing • Mirror Images
• Reverberation • Slice Thickness
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Acoustic Shadowing Acoustic Enhancement

• Caused by interfaces/structures that highly attenuate • Increased brightness posterior to fluid- filled structures
sound by reflection (gas) or absorption (calculi) • Interfaces deeper will produce stronger reflections (bright)
• Bone, calculi, gas, scar tissue and foreign bodies produce it * Not all fluid- filled structures are echo- free (abscess,
• Good diagnostic feature hemorrhagic cysts); this may help!
• Clear shadow (Calculus), dirty shadow (gas) • Some solid lesion also produce it like Fibroadenoma

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Edge Shadowing Reverberation

• Occurs when beam bounces repeatedly between ≥2 interfaces
• A reflective/refractive effect seen deep to the margins of rounded structures that have a
speed of sound different from surrounding tissue. • With each reverberation cycle, some echoes return to transducer,
causing multiple echoes at increasing depth in display.
• Frequently seen with from cystic structures, appearing as very narrow shadows in line with
the beam direction, arising immediately deep to the edge of the structure • Common in 90 degree
Elimination:
• Altering angle
• Harmonic imaging
• Abdomen: increased transducer pressure

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Comet Tail Ring down

• Localized reverberation artifact • A resonance phenomenon arising from gas bubbles.
• Seen deep to crystalline material (cholesterol stones), metal structures (surgical staples) • Frequently seen in abdominal imaging (bowel gas)
and air in the lungs • Useful indicator of the presence of gas bubbles in abnormal areas, such as pneumobilia

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Slice thickness Mirror image

• Echoes displayed in 2D ultrasound images have arisen from 3D volume scanned by beam • Surfaces that reflect more light act as mirrors (Gas; 100 % reflector)
• Compression from 3D to 2D images results in slice thickness artifact
• Seen in fluid-filled structures (bladder, blood vessels, gallbladder) • Can it produce problem?
• DDx: Bladder (sludge; rule patient to side); vessel (thrombosis (axial)
• Harmonic imaging

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Mirror image… Can lead to misdiagnosis Ultrasound Training Course; Basics and Beyond Basics
Dr. Hidayatullah Hamidi
• Gas in rectum: Mirror image of bladder as pelvic cystic mass
• Bowel gas: Uterus as duplicated in transvaginal ultrasound
• Bowel gas : singleton pregnancy can appear as twins
• Skull bone: cephalhematoma as subdural hematoma; unnecessary further investigation

The End & Best of Luck

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