Figure 9.6. Continued.

by Z-axis modulation (brightness variation) of the oscilloscope beam. One

advantage of this system is that cert' .in portions of the gray scale can be
enhanced to bring out specific feati /es of the picture. Also, the image can
be changed so that warm spots appear dark instead of light, as they usually
do. All these enhancement measures can be performed while the subject is

being scanned. A Thermovision system is shown in Figure 9.6.

9.2. PRINCIPLES OF ULTRASONIC MEASUREMENT

Recently, many of the innovations of medicine have taken place
because of the use of ultrasound. By definition, ultrasound is sonic energy
at frequencies above the audible range (greater than 20 kHz). Its use in
medical diagnosis dates back to the period following World War II and is
a direct outgrowth of the military development of sonar, in which pulsed
ultrasound was used in the detection of submarines and other underwater
objects by reflection of the ultrasonic waves.

9.2.1. Properties of Ultrasound

Like other forms of sonic energy, ultrasound exists as a sequence of alternate

compressions and rarefactions of a suitable medium (air, water, bone,

255
256 Noninvasive Diagnostic Instrumentation

and is propagated through that medium at some velocity. Its

tissue, etc.)
behavior also depends on the frequency (wavelength) of the sonic energy
and the density and mechanical compliance of the medium through which it
At the frequencies normally used in diagnostic applications, ultra-
travels.
sound can be focused into a beam and obeys the laws of reflection and
refraction.
Whenever a beam of ultrasound passes from one medium to another,
a portion of the sonic energy is reflected and the remainder is refracted,
as shown in Figure 9.7. The amount of energy reflected depends on the
difference in density between thetwo media and the angle at which the
transmitted beam medium. The greater the difference in media,
strikes the
the greater will be the amount reflected. Also, the nearer the angle of
incidence between the beam and the interface is to 90 ° the greater will be
the reflected portion.

, = ., .. ^ Figure 9.7. Reflection and refraction

Medium 1 = Medium 2 _ , , r i

^ of ultrasound at an interface between

1 media of different densities.

At interfaces of extreme difference in media, such as between tissue

and bone or tissues and a gas, almost all the energy will be reflected and
practically none will continue through the second medium. For this reason,
the propagation path for ultrasound into or through the body must not
include bone or any gaseous medium, such as air. In applying ultrasound to
the body, an airless contact is usually produced through use of an aqueous
gel or a water bag between the transducer and the skin.
Table 9.1 lists the density and other properties of various materials,
including several of biological interest. The temperature and ultrasonic
frequency are given for most of the measurements. Note that the density of
water and most body fluids and tissues is approximately 1.00 g/cm\ Benzene
has a density of 0.88, whereas the density of bone is almost twice as great
(1.77g/cm^).
 Table 9.1. ULTRASONIC CHARACTERISTICS OF MATERIALS^
Attenuation Constant,

a = cfP

Characteristic
Temperature Density Velocity Impedance x 10^
terial rc) (g/cm'J (m/sec) (kg/mVsec) ^f(MHz) a (per cm)
ter 40 0.992 1529 1.517 1 2 0.00025
ne, 0.9*^0 normal 40 0.998 1539 1.537
tor oil 40 0.941 1411 1.328 1.67 0.037
in, average 37 1.03 1510 1.56 0.11
5 0.44
rtical gray matter 37 1.03 0.08
Ileal white matter 37 1.03 0.14
scle, skeletal 37 1.07 1570 1.68 0.13
37 0.97 1440 1.40 0.05
le, skull 37 1.77 3360 6.00 0.5 1.7 0.37
1.2
1.5 2.5
2 4.0
2.5 5.9
3 8.1
3.5 10.5
n 1.63
er 1.08 1510 1.63 2 0.19
od 1.01 1550 1.56 2 0.04
:ite 3.23
tumor
lin

Meningioma 5 0.73
jlioblastoma 5 0.38
Metastatic 5 0.50
Iney 1.04 1560 1.62 2 0.27

Vqueous humor 1.00 1500 1.50

/itreous humor 1.00 1530 1.53
.ens 1.14 1630 1.85
izene 0.88 1320 1.17
3ber
Ihoc 1.00 1560 1.56
loft 0.95 1050 1.00
een 1.05 1570 1.65

om W. Welkowitz and S. Deutsch, Biomedical Instruments: Theory and Design, Academic Press, New York,
6; by permission.

257
 ,

2S8 Noninvasive Diagnostic Instrumentation

The velocity of sound propagation through a medium varies with the

density of the medium and its elastic properties. It also varies with tempera-
ture. As shown Table 9.1, the velocity through most body fluids and
in
soft tissues is narrow range around 1550 m/sec. The velocity in
in a fairly
water is just slightly lower (1529 m/sec). Note that the velocity of sound
through fat is significantly lower (1440 m/sec) and through bone is much
higher (3360 m/sec).
Every material has an acoustic impedance, which is a ratio of the
acoustic pressure of the applied ultrasound to the resulting particle velocity
in the material. Since acoustic impedance is a complex value, consisting of
both resistive and reactive components, a simpler term, called characteristic
impedance, is more often used. The characteristic impedance of a material
is the product of its density and the velocity of sound through it. Table 9.1

gives the characteristic impedances of several materials.

Also given in Table 9.1 is an attenuation constant, <x for each material.,

As ultrasound travels through the material, some of the energy is absorbed

and the wave is attenuated a certain amount for each centimeter through
which it travels. The amount of attenuation is a function of both the
frequency of the ultrasound and the characteristics of the material. The
attenuation constant, a is defined by the equation.
,

amplitude at point X _ n
amplitude at A" + 1 unit distance

As shown in Table 9. 1
a (per cm) = cf^

where c = proportionality constant

/= ultrasound frequency
p = exponential term determined by the properties of the material

This formula shows that attenuation increases with some power of the
frequency, which means that the higher the frequency, the less distance it

can penetrate into the body with a given amount of ultrasonic energy. For
this reason, lower ultrasound frequencies are used for deeper penetration.
However, lower frequencies are incapable of reflecting small objects. As a
rule, a solid object surrounded by water or saline must be at least a quarter-
wave thick in order to cause a usable reflection. Thus, for finer resolution,
higher frequencies must be used. Ultrasound frequencies of 1 to 15 MHz
are usually used for diagnostic purposes. At 2 MHz, distinct echoes can be
recorded from interfaces 1 mm apart. Higher-frequency ultrasound is also
more subject to scattering than ultrasound at lower frequencies. However,
the high-frequency ultrasound beam can be focused for greater resolution
at a given depth.

1^1^
9.2 Principles of Ultrasonic Measurement 2S9

Another useful way of assessing the attenuation of ultrasound as it

penetrates the body is the half-value layer of the medium given in Table 9.2.
The half-value layer is the depth of penetration at which the ultrasound
energy is attenuated to half the applied amount.

Table 9.2. ULTRASOUND ABSORPTION

Type of Tissue Frequency (MHz) Half- Value Layer (cm)

Blood 1.0 35.0

Bone 0.8 0.23
Fat 0.8 3.3
Muscle 0.8 2.1

(From Feigenbaum, Echocardiography, 2nd Edition, Lea and

Febiger, 1976 by permission.)

A
well-known characteristic of ultrasound frequently utihzed in bio-
medical instrumentation is the Doppler effecty in which the frequency of the
reflected ultrasonic energy is increased or decreased by a moving interface.
The amount of frequency shift can be expressed in the formula:

A/= 2_K
X
where / = shift in frequency of the reflected wave
V = velocity of the interface
X = wavelength of the transmitted ultrasound

The frequency increases when the interface moves toward the trans-
ducer and decreases when it moves away. With an ultrasound frequency of
3 MHz, about 40 Hz for each cm/sec of interface velocity.
the shift is

A way
to understand this in general terms is to consider what
useful
happens if an automobile with its horn sounding passes by on the street.
The pitch or perceived frequency of the sound seems higher as the car is
approaching but seems lower as it goes away. This is an example of the
Doppler frequency shift. When ultrasound is reflected from a moving object,
the measured frequency shift is proportional to velocity.

9.2.2. Basic Modes of Transmission

Ultrasound can be transmitted in various forms. Following are the modes of

transmission most commonly used in diagnostic medical applications:

1 . Pulsed ultrasound: In this mode, ultrasound is transmitted in

short bursts at a repetition rate ranging from 1 to 12 kHz.
280 Noninvasive Diagnostic Instrumentation

Returning echoes are displayed as a function of time after trans-

mission, which is proportional to the distance from the source to
the interface. Movement of interfaces with respect to time can
also be displayed. The burst duration is generally about 1 ^sec.
Pulsed ultrasound is used in most imaging applications.
2. Continuous Doppler: Here a continuous ultrasonic signal is
transmitted while returning echoes are picked up by a separate
receiving transducer. Frequency shifts due to moving interfaces
are detected and recorded and the average velocity of the targets
is usually determined as a function of time. This mode always

requires two transducer crystals, one for transmission and one

for receiving, whereas any of the pulsed modes can use either
one or two crystals. Continuous Doppler ultrasound is used in
blood flow measurements (see Chapter 6) and in certain other
applications in which the average velocity is measured without
regard to the distance of the sources.
3. Pulsed Doppler: As in pulsed ultrasound, short bursts of ultra-
sonic energy are transmitted and the returning echoes are received.
However, in this mode frequency shifts due to movement of the
reflected interfaces can be measured in order to determine their
velocities. Thus, both the velocity and distance of a moving
target can be measured. In a typical appHcation, three cycles
of 3 -MHz ultrasound are transmitted per pulse at a pulse rate
of 4 to 12 kHz.
4. Range-gated pulsed Doppler: This mode is a refinement of
pulsed-Doppler ultrasound, in which a gating circuit permits
measurement of the velocity of targets at a specific distance
from the transducer. The velocity of these targets can be measured
as a function of time. With range-gated pulsed Doppler ultra-
sound, the velocity of blood can be measured, not only as a
function of time, but also as a function of the distance from
the vessel wall.

In any of the above-described modes, the most effective frequency of

the ultrasound depends upon the depth of penetration desired and the
required resolution.

9.2.3. Ultrasonic Imaging

The most widely used applications of ultrasound in diagnostic medicine

involve the noninvasive imaging of internal organs or structures of the
body. Such imaging can provide valuable information regarding the size,
location, displacement, or velocity of a given structure without the necessity
9.2 Principles of Ultrasonic Measurement 261

of surgery or the use of potentially harmful radiation. Tumors and other

regions of an organ that differ in density from surrounding tissues can be
detected. In many instances, ultrasonic techniques have replaced more risky
or more traumatic procedures in clinical diagnosis.
Imaging systems generally utilize the pulsed ultrasound or pulsed
Doppler mode. Instrumentation must include an electrical signal source
capable of driving the transmitter, which consists of a piezoelectric crystal.
The same crystal can be used for receiving echoes or a second crystal may
be used.
After amplification, the received information is displayed in one of
several display modes. There is some confusion in the literature in the
definition of some of these modes. For example, some authors consider the
M-scan used in echocardiography (Section 9.3.2) as a form of the B-scan
mode rather than a separate mode. While it is true that these two modes are
very similar, differences in the information presented make it necessary to
distinguish between the two in order to properly interpret the display.
Also, some authors have adopted terminology from military sonar displays
which is not appropriate to imaging in medical applications. The following
definitions are those most generally found in the literature and are used
consistently in this text:

1. A-scan display [Figure 9, 8(a)]: This is the simplest form of

display. Each transmitted pulse triggers the sweep of an oscillo-

scope. That pulse (often attenuated) and the returning echoes
are displayed as vertical deflections on the trace. The sweep is
calibrated in units of distance, and may provide several ranges
in order to accurately determine the distance of the interfaces of
interest. is varied with the sweep to
Often, the amplifier gain
compensate for the lower amplitude of more distant echoes. In
most cases the transducer is kept stationary so that any move-
ment of echoes along the trace will be the result of moving
An example of an A-scan display is
targets. that of the echo-
encephalogram.
2. M'Scan display: As A-scan mode, each transmitted pulse
in the
triggers the oscilloscope sweep; however, the received pulses are
used to brighten the trace rather than control the vertical deflec-
tion, as shown in Figure 9.8(b). The quiescent brightness level
is set below the visibiUty threshold so that only the echoes,
which appear as dots with brightness proportional to the intensity
of each echo, can be seen. For the M-scan, the transducer is held
stationary so that the movement of the dots along the sweep
represent movement of received targets. If photographic paper
is slowly moved past the face of the oscilloscope so that each
 Received
echoes

(a)

(b)

Figure 9.8. Ultrasound Display Principles, (a) Typical A-scan.

Echoes cause vertical deflection of oscilloscope pattern, (b) Cor-
responding display in which echoes control brightness of oscil-

loscope beam. This principle is used in both B- and M- scan

displays.

Figure 9.9 M-scan of moving and stationary target with cor-

responding A-scan.

Transmitted Echo from Echo from

pulse moving stationary
target target
A

M-scan

K A
Corresponding A-scan
9.3 Ultrasonic Diagnosis 263

trace lies immediately adjacent to the one preceding it, the dot
representing each target will trace a line on the paper as shown
in Figure 9.9. A stationary target will trace a straight hne,
whereas a moving target will trace the pattern of its movement
with respect to time. A light-pen recorder in which the intensity
of the light source can be controlled may be used instead of an
oscilloscope to produce a chart record of themovement of echoes
with respect to time. An example of an M-scan recording is the
echocardiogram shown in Figure 9.12.
3. B-scan display: While the M-scan is used to display the movement
of targets with respect to time, the B-scan presents a two-dimen-
sional image of a stationary organ or body structure. As in the
M-scan, the brightness of the oscilloscope or light-pen beam is
controlled by returning echoes; however, in the B-scan the trans-
ducer is moved with respect to the body while the vertical deflec-
tion of the oscilloscope or movement of the chart paper is made
to correspond to the movement of the transducer. The movement
may be linear, circular, or a combination of the two, but where
it is anything other than Unear, the sweep must be made to
compensate for the variations in order to provide a true two-
dimensional display of the segment being scanned. Examples
of B-scan displays are shown in Figure 9.15.

9.3. ULTRASONIC DIAGNOSIS

The applications of ultrasonic methods to medicine are many and
varied. The techniques are used in cardiology, for abdominal imaging, in
brain studies, in eye analysis, and in obstetrics and gynecology. The records
obtained have various names, which usually include the words *'echo" or
**sono." For example the echocardiogram, analogous to the electrocardio-
gram, is a record of ultrasonic measurements in the heart. The echoen-
cepJtalogram is a record obtained from the brain. A general term used,
especially with eye analysis, is the ultrasonogram. Examples of these will
be presented later in this section. Multiple names have been coined for the
instruments used, including many trade titles. Typical designations are
ultrasonograph, ultrasonoscope, and sonofluoroscope. The latter is used
essentially for moving structures, whereas some of the devices are used for
staticimages.
Before discussing some of the components and specific medical fields,
perhaps a general overview and illustration will give the reader a perspective.
Figure 9.10 is sl phased-array ultrasonograph, which represents a class of
instruments that has recently appeared. It is virtually an entire medical
ultrasound laboratory in one mobile instrument.