featurearticle
did you put colour on that?
BY MICHELE ROSE, AMS, APPLICATIONS SPECIALIST, NSW.
We commonly use Doppler to help us
characterise and quantify pathology
in our patients. But there are various
forms of Doppler available to us. Which
do we use when and what can we do
if we’re not seeing what we expected?
Before turning the Doppler back off
again I hope to help you explore the
options.
Firstly, we’ll need an understanding
of haemodynamics (another article all
together so for our purposes it will be
assumed knowledge) and to remember the
Doppler equation for any of this to make
sense. So a reminder of the latter:
fd = ft 2 v cos θ / c or
v = fd c / 2ft cos θ
where v = source velocity, fd = Doppler
frequency shift, c = speed of sound in soft
tissue, ft = transmit frequency, θ = the
angle between the line of sight and the
direction of blood flow and the factor of 2
accounts for the double Doppler shift which
occurs between the transducer and the
moving source
And fd = fr - ft
where fr = receive frequency
The Dopplers we use include:
Pulse Wave Doppler
Pulse wave (PW) or spectral Doppler is a
display of positive and negative velocities
(calculated using the above formulae) at
a position in the patient indicated by a
sample gate. Second only to continuous
wave Doppler for its sensitivity, PW has the
14 issue 2, 2006
advantage of demonstrating only Doppler
shifts from a chosen area. The relatively
small sample area is sampled many times
prior to velocity calculation allowing a good
signal to noise ratio and sensitivity to low
flow. It’s not the quickest way to assess
a large area but it does provide us with
velocity information. Combine this with
haemodynamics and we know both the
conditions the blood has travelled through
as well as that it’s approaching.
Colour Doppler
Colour Doppler (CD) is a colour coded
representation of the mean Doppler shift
calculated over the observation time.
Autocorrelation is usually used as a
statistical averaging process to calculate
this mean Doppler shift. In generous terms
it is a visual display of fr - ft (frequency
received minus frequency transmitted).
This may be a positive or negative value
and so the colour coding is directional and,
like PW, this is relative to the transducer.
Due to the reference map displayed to
one side of the image showing cm/second
it is commonly thought that velocity is
being displayed but this is not the case.
By significantly reducing the number of
times each line of sight is sampled, CD
allows us to assess a much larger area at
a time but the trade off is lower sensitivity
to low flow and a lack of time to perform
velocity calculations. However it can
and does reduce examination time by
demonstrating areas of greater frequency
shift which can be interpreted as relative
velocity, providing guidance for an angle
corrected PW gate and subsequent
velocity calculation.
Power Doppler
Also known as Angio, Energy and
Amplitude Doppler, Power Doppler (PD) is
a coloured representation of the strength
(amplitude) of the frequency shift. PD
essentially represents the volume of
red blood cells (the greater the number,
the greater the signal strength). It has
greater sensitivity for low flow states
due to its lower PRF and higher frame
averaging giving a better signal to noise
ratio. Displaying the strength of the signal
rather than mean frequency shift (which is
dependant on angle of incidence) allows
better visualisation of blood travelling
parallel to the transducer face. But it
also means direction and velocity cannot
be calculated. PD may also suffer from
reduced penetration due to attenuation.
Directional Power Doppler
Directional Power Doppler (DPD) is as
its name implies. DPD makes use of the
directional information from the Doppler
shift and combines it with the amplitude of
PD. DPD is certainly more sensitive than
CD but the higher frame averaging results
in loss of temporal resolution (refer to time
smooth).
Short Pulse Doppler
“The pulses used for colour flow imaging
are typically three to four times longer
than those for the B-mode image, with a
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corresponding loss of axial resolution” [1].
Advanced Dynamic Flow (ADF) is a short
pulse Doppler technique which results in
a range/spectrum of frequencies being
transmitted. The short pulse means that
it doesn’t suffer the loss of resolution
described above and the directional
Doppler display has temporal and spatial
resolution similar to that of B mode. ADF
also has the ability to display both low and
high flow states simultaneously. The trade
off is that the wider transmit spectrum also
widens the range of Doppler shifts making
relative velocity more difficult to assess.
Like for colour and power Doppler, PW is
needed to assess velocity.
Using these complementary Doppler
techniques in combination affords us the
most information. To help you get the most
out of Doppler the following is a description
of common machine controls and how
they will affect your Doppler display. As
manufacturers have differing names for
the controls available to you it may be
necessary to consult your Applications
Specialist for a ‘translation’ of the terms I
have used.
Parameters Applicable to Colour
and Pulse Wave Doppler
Presets
Just like B mode, you need to consider
the default settings of the preset you are
using. For example, your carotid preset is
set to default to settings that are suitable
to assess average flow in a common
carotid artery. Such factors as direction,
scale, filter, gain and angle for both CDI
and PW are set with the assumption that
this is where you will begin your scan.
You need to adjust these settings as you
negotiate changes in vessel position and
flow characteristics, be they physiological
or pathological. Those incidental nodes or
thyroid nodules are often more quickly and
accurately assessed by a quick change
in presets, especially until you become
confident with Doppler.
Frequency
Whilst we are familiar with making
adjustments for B mode imaging,
changing Doppler frequency can be
overlooked. Blood cells are smaller than
the wavelength of ultrasound and so act
as scatterers (not reflectors). The returning
echoes are much weaker than those
soundeffects
did you put colour on that?
reflected from soft tissue. So to receive
echoes from the same depth, PW and CD
frequencies need to be lower than that
for B mode. But “a doubling of transmit
frequency results in a return echo 16
times stronger” [2]. Increasing transmit
frequency increases the intensity of
echoes from blood (and hence sensitivity)
and can be helpful when assessing veins
such as the great saphenous where less
Fig 1. Insufficient gain makes visualisation of this
penetration is required. Transmit frequency
PW trace difficult.
not only determines penetration but also
governs the maximum detectable Doppler
frequency. Lowering the transmit frequency
(which may include changing transducer)
lowers the Doppler shift and may be the
answer for reducing or eliminating aliasing
in that really tight stenosis when the
maximum PRF has been reached.
Invert
It is common to use the invert or reverse Fig 2. Increased gain settings introduces excessive noise.
controls that allow us to display arterial
flow as toward the transducer and venous
as away. It is essential to remember
that direction of flow is relative to the
transducer. All systems indicate on the
monitor display if the CD and/or PW have
been inverted.
Gain
The amplification of the return signals
is determined by the PW or CD gain. If Fig 3. Appropriate gain settings optimise
set too low the colour or PW signals are demonstration of flow within this vessel.
underwritten and may be missed (fig 1).
Too high and too much noise is introduced
(fig 2). For colour, adjusting the gain so as
to induce noise and then turning it down
just enough to remove the noise will give
optimum gain settings (fig 3). When gain
settings are such that noise makes the
trace difficult to see, altering the dynamic
range of the trace or applying a PW map
may help to make things clearer.
Fig 4. Split screen. Left image demonstrates aliasing
Pulse Repetition Frequency (PRF) (PRF too low). Right image shows inadequate colour
filling (PRF too high).
PRF, velocity range and scale all refer to
the sampling rate. The PRF needs to be
at least twice the Doppler shift in order to
prevent aliasing. For slow flow the PRF
needs to be lower to allow time between
sampling. So if the PRF is too high, poor
filling of the vessel with colour occurs, too
low and aliasing will result (fig 4). As the
minimum filter setting is usually linked to
velocity range it is important to reduce the
scale for slow flow to maximise sensitivity Fig 5. High PRF and high filter settings result in sub
(figs 5 & 6). optimal demonstration of the venous flow in this vessel.
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did you put colour on that?
Baseline
Whilst commonly altered for PW Doppler
(figs 7 & 8), baseline is underutilised for CD.
Baseline represents the position of zero flow
and divides the display into forward and
reverse flow. Changing the baseline allows
you to optimise your Doppler display and
prevent aliasing without changing the scale
(fig 9). This allows you to maintain a lower
PRF for slow flow or allows you to display
high Doppler shifts without increasing the
PRF or reducing transmit frequency to
prevent aliasing.
Fig 6. Low PRF and low filter settings optimise the
visualisation of low velocity flow within the same
vessel as figure 5.
Fig 7. Aliasing can be corrected by altering the
position of the baseline.
Fig 8. Correction of the trace seen in figure 7 by
changing the baseline.
Fig 9. Split screen images demonstrate the change in
the display when the baseline is lowered (left to right).
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Filter
Filters are a user defined threshold and
are visually seen as a black or ‘no fill’
area either side of the CD (fig 13) or PW
baseline. We use them to eliminate the
low frequency noise generated by vessel
wall motion but it will also filter out low
frequency Doppler shifts in regions of low
velocities (figs 14 & 15). An arterial preset
Fig 10. Demonstrates the change in the spectral will have higher default filter levels than
trace as the angle of incidence increases. a venous preset, so if looking for trickle
flow in an ICA you’ll need to remember to
reduce the filter. Remember that CD and
PW have independent filter settings and
also that the minimum filter settings and
scale are commonly linked.
Dynamic Range
Adjusting the dynamic range of your
Doppler alters the display as it would
for B mode. Use it to enhance a trace
Fig 11. A relatively poor spectral trace is
seen with a low angle of incidence.
Fig 13. This colour images demonstrates the difference
seen with different filter settings (higher on the right).
Fig 12. The improvement in image quality can be
seen in both the colour and spectral image with a
higher angle of incidence.
Angle of Incidence
The steering of the angle of incidence
or line of sight affects the Doppler image
due to it changing the Doppler shift.
The closer to 0 degrees the angle
of incidence is to the blood flow the
greater the Doppler shift. In figure 10 Fig 14. When the filter is set too high important
the gate remains in the same position frequency shift information is removed from the
spectral trace.
but as the angle of incidence becomes
closer to being along the axis of the
vessel, the Doppler shift becomes
greater. This applies to CD and PW
and is a sometimes overlooked means
of achieving better Doppler signals
(figs 11 & 12). Without changing acoustic
windows we may be limited in the angles
available to us though. For example, when
scanning vertebral arteries we need to
steer the PW gate between the transverse Fig 15. The same vessel as seen in figure 14 with
processes to avoid the bony interface. lower (and more appropriate) filter settings.
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(figs 16 & 17) or CD display, reduce the
display of noise or make a trace easier to
read on film.
Fig 16. A high dynamic range degrades the spectral
display.
Fig 17. A lower dynamic range (same vessel as figure
16) improves visualisation of the spectral trace.
Parameters Applicable
to Color Doppler
Colour Box Size and Depth
You’ll notice that as the colour box
becomes wider, the frame rate reduces
(figs 18 & 19). This is because of the
multiple pulses needed for each line of
sight. Most systems use multiple beam
formers to reduce the loss of frame rate,
however spatial resolution is still reduced
by increased colour box width. Colour
box depth affects frame rate to a lesser
degree and the loss is governed by how
posterior the back of the box is rather
than its overall height. If you’re after good
spatial resolution, such as in fetal cardiac
scanning, it is essential that you use a
narrow colour box. The depth required may
not be something you have control over but
as always there are image quality benefits
in reducing it.
Data Number
May also be known as pulse sample
count, sensitivity, packet size or ensemble
length. Adjusts the number of sampling
data or number of pulses sent along
each scan line to acquire CD information.
soundeffects
Fig 18. This narrow box allows a frame rate
of 7 frames per second (fps).
Fig 19. Widening the box decreases the frame
rate to 4fps.
Fig 20. Increasing the data number improves
sensitivity but decreases the frame rate (left image
compared to right).
Increasing data number will result in slower
frame rates but increases the accuracy
of flow estimates and more importantly
sensitivity to slow flow due to increased
observation time (fig 20).
Time Smooth
Time smooth adjusts temporal resolution by
varying the amount of frame averaging. It’s
used to smooth out flow characteristics, giving
the flow a more even look. If you understand
the flow characteristics of the vessel you’re
looking at, maintaining temporal resolution
is very helpful. Looking at the ICA and ECA
in the transverse plane you can quickly
differentiate the two as the ECA has little filling
during diastole (fig 21). This is comparable to
the waveforms that show a lower resistive bed
(more diastolic flow) for the ICA (fig 22) than
the higher resistive ECA (fig 23).
did you put colour on that?
Fig 21. The different flow patterns in the ICA
and ECA are easily seen.
Fig 22. The low resistance ICA waveform.
Fig 23. The high resistance ECA waveform.
Spatial Smooth
Sometimes called edge control, spatial
smoothing assigns a colour value to the
pixel based on a comparison of that pixel to
those adjacent. This can be used to make
flow look smoother and more continuous.
Threshold
Colour balance or priority determines the
threshold value at which colour will be
displayed if a Doppler shift is detected.
Set the balance too low and you’ll get poor
colour fill, more so if the vessel initially
has low level echoes within it. Too high
and colour will be displayed in areas of
soft tissue, especially when there is tissue
movement (fig 24). Lowering the balance
when scanning hepatic veins close to the
heart will allow you to show flow without
colour display artefacts.
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did you put colour on that?
Fig 24. This split screen image demonstrates colour
in areas of soft tissue (left) when balance is set too
high and inadequate colour filling of the vessel (right)
when set too low.
Fig 25. This split screen image demonstrates the
difference in the display with higher (left) and lower
(right) cut off thresholds.
Fig 26. An example of four different colour maps
applied to the same image.
Some systems allow you to change this as
a post processing function allowing you to
correct the display without rescanning.
When using PD, threshold settings may
have a different name such as cut off.
As with colour balance, cut off allows
you to filter out tissue movement noise
and can be adjusted post freeze. As PD
is better for low flow, cut off is effective
when used during augmentation for a DVT
study, especially in the calf. It allows flow
to be seen without the noise from tissue
movement during augmentation (fig 25).
Colour Maps
Variations of colour hues can be used
to demonstrate the range of frequencies
detected (fig 26). This can be a matter of
personal taste and often the type of map
18 issue 2, 2006
you trained on becomes your preferred.
Any map can be used as long as you
understand what it’s displaying. For PD the
variations reflect signal strength or number
of red blood cells.
Parameters Applicable
to Pulse Wave Doppler
Gate Position & Size
The PW gate width is defined by the
machine but its depth/size and position
within the vessel are user defined. The
fastest flow is in the centre of the vessel
(fig 27) and whilst we need to scan a
vessel along the long axis to be able to
angle correct, the position of the gate
within the transverse plane will also
influence the Doppler signal. If the gate
isn’t in the centre of the vessel in both
planes the velocity calculated and the
amplitude of the spectrum will be lower.
Fig 27. Higher velocity flow is seen in the centre of
the vessel.
Fig 28. A narrow gate results in a clearer trace with
less spectral broadening.
Fig 29. A larger gate results in spectral broadening.
A large gate can be helpful when searching
for flow in a near occluded vessel or if
you are unable to keep the gate within the
vessel (due to movement). However the
increased range of Doppler shifts will result
in spectral broadening and a reduction
in trace brightness (figs 28 & 29). The
presence of spectral broadening normally
alerts us to flow disturbance but will also
be present if the gate is not positioned mid
flow or when the gate is large.
Angle Correction
Unless you tell the machine otherwise,
velocity calculations are made with the
assumption that the beam is travelling
along the long axis of the blood flow.
Except for when this is true, the velocity will
be underestimated. Angle correction allows
us to align to the blood flow (cos θ ) and
obtain more accurate velocities. All systems
will alert you when θ exceeds 70 degrees as
Fig 30a.
Fig 30b.
Fig 30c.
Figs 30a-30c. Note the change in the calculated velocity
with the change in angle correction.
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the percentage error becomes too large.
It then becomes necessary to scan from a
different approach to reduce this angle or
change the steering of the angle of incidence.
Maps
Like dynamic range these can be used
to make the trace better seen on film or
enhance the trace to help differentiate it
from noise when excessive gain is needed
or there is a lot of spectral broadening
(fig 31). Your system may also allow you
to alter the post processing curve allowing
further manipulation of your Doppler trace.
Sweep Speed
Alters the time over which the Doppler
trace is displayed. A fast sweep speed
will allow you view the trace over a longer
time or more cardiac cycles (fig 32) and
is also useful for showing prolonged
venous reflux. Reducing the sweep speed
decreases the time display making it
easier to more accurately measure time,
especially acceleration time (fig 33).
A note about artefacts
There are many that could be discussed
but won’t with the exception of two.
As I have referred to aliasing several
times I feel compelled to comment on it.
Aliasing occurs when the PRF is not at
least twice that of the Doppler shift. Those
components of the PW or CD image that
are aliased are displayed in the opposite
channel or direction. Aliasing makes it
impossible to measure maximum velocity
in PW and so should be avoided by
adjusting baseline, increasing scale/PRF,
decreasing cos θ and/or reducing transmit
frequency. In CD aliasing can be a friend.
If the settings are correct for ‘normal’ flow
then flow above this level will be shown as
aliasing and help draw your eye to an area
SIG
that needs PW evaluation.
soundeffects
Fig 31. An example of four different PW maps
applied to the same spectral trace.
Fig 32. A fast sweep speed demonstrates many
cardiac cycles simultaneously.
Fig 33. A slower sweep drags out the spectral
trace allowing for more accurate measurements of
acceleration time.
Fig 34. Twinkling artefact. [Image courtesy of
Craig Cairns.]
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did you put colour on that?
Another useful artefact is known as the
‘Twinkling Artefact’. This is seen as a
“rapidly changing mixture of red and
blue behind presumed calcifications” [2]
and is generated by the multiple strong
reflections caused by the relatively rough
but echogenic surface of calcium (fig 34).
The twinkling artefact was investigated by
Rahmouni et al and found to be present
in granular structures but not smooth
surfaces [3]. PW detects no Doppler shift
and so can confirm the random colour
display is due to this artefact. With an
increased use in compound imaging and
the potential loss of B mode artefacts
such as shadowing, the use of CD and the
presence of ‘twinkling artefact’ can improve
clinical confidence about the presence of
calcifications. It is best not to saturate your
image with colour though as you may mask
its presence and it has been reported that
the colour focal position also needs to be
considered for greater accuracy.
References
1. Deane C. Doppler ultrasound principles
and practice. Diploma in Fetal Medicine
& ISUOG Educational Series – Doppler
in Obstetrics [serial on the Internet].
2002 [cited 2006 Apr 20]. Available
from: http://www.thefetus.net/html/
doppler/capitulos-html/chapter_01.htm.
2. Ferrara K, DeAngelis G. Color Flow
Mapping. Ultrasound Med Biol.
1997;23(2):321-45.
3. Rahmouni A, Bargoin R, Hermant A,
Bargoin N, Vasile N. Colour Doppler
Twinkling Artefact in Hyperechoic
Regions. Radiology. 1996;199:269-71.
Suggested Further Reading
1. Gent R. Applied Physics and
Technology of Diagnostic Ultrasound.
Australia: Openbook Publishers; 1997.
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