EULAR on-line course on Ultrasound

B-mode MSUS and Doppler MSUS

physics; indications and limits of
MSUS; normal findings and basic
abnormalities; artefacts; image
documentations; how to write a
report on MSUS findings

Marcin Szkudlarek, Lene Terslev

IN-DEPTH DISCUSSION I

Optimizing the Doppler settings

 B-mode MSUS and Doppler MSUS physics; indications and limits of MSUS; normal findings and basic abnormalities;
artefacts; image documentations; how to write a report on MSUS findings– In-depth discussion 1 – Module 1

Assessing a patient with clinical signs of synovitis ultrasound examination may reveal grey scale synovial
hypertrophy in the joint but when adding the Doppler modality to the examination there seems to be no
inflammatory flow (Figure1a). Does this mean that there is no hyperemia in the joint?
This depends on the Doppler sensitivity of the ultrasound machine. The higher the Doppler sensitivity is the
more you can rely on Doppler negative findings. The lower the Doppler sensitivity is the more likely it will be
that it simply cannot detect the flow present in the joint.
The Doppler sensitivity is always higher on high-end equipment than intermediate and low-end equipment.

Another reason for not detecting any flow could be that the machine is simply not adjusted for low velocity
flow (Figure 1b). When working with inflammatory flow (low velocity flow) it is important to pay particular
attention to the settings and the most important ones are dealt with in the following sections and an overview
is shown in table 1.

1. Selection of Doppler modality

Colour or power Doppler modality may be selected – which one is the optimal for slow flow information? It is
generally believed that power Doppler is always the most sensitive modality but this no longer seems to be the
case in the newer high-end machines where colour Doppler may have higher sensitivity than power Doppler
(Figure 2). In low and intermediate range machines power Doppler always has the highest sensitivity. The
selection ofcolour or power Doppler therefore depends on the machine.

Figure 1. MCP joint with synovial hypertrophy. In image (a) there is no inflammatory flow but after adjusting
the Doppler settings inflammatory flow may now be seen in the joint (b).

©2007-2015EULAR 2
 B-mode MSUS and Doppler MSUS physics; indications and limits of MSUS; normal findings and basic abnormalities;
artefacts; image documentations; how to write a report on MSUS findings– In-depth discussion 1 – Module 1

Figure 2. Flow in the thenar muscles. In image (a) the flow is shown with colour Doppler and in (b) with power
Doppler. Power Doppler is not aways the most sensitive Doppler modality. It must be tested on the individual
machines.

2. Frequency

As in grey scale US a lower Doppler frequency will allow more penetration but alsoa more grainy Doppler
image (larger colour pixels). A higher Doppler frequency gives a more detailed image of the vessels but at the
expense of penetration. The trade-off between penetration and sensitivity is somewhat unpredictable and
resolution is not important here. The ability to depict slow flow in a small vessel (with a weak Doppler
reflection) is enhanced by a lower frequency (because the weak reflection has more penetration) but is also
enhanced by a higher frequency because the Doppler shift is higher (if the reflection is powerful enough to
penetrate). The optimal Doppler frequency must be found by testing the machines and cannot be determined
in theory (film clip 3a&b – go to images section)

3. Pulse Repetition Frequency (PRF) and wall filter

PRF is the Doppler sampling frequency of the transducer (how many pulses of sound are emitted per second
into the tissue) and is reported in Hz. The sensitivity to slow flow is affected by PRF adjustments in both colour
and power Doppler. When a high PRF is selected it is assumed that the investigator is interested in high
velocities, and therefore filters are added to remove noise (i.e pulsation from moving arterial walls) -so called

©2007-2015EULAR 3
 B-mode MSUS and Doppler MSUS physics; indications and limits of MSUS; normal findings and basic abnormalities;
artefacts; image documentations; how to write a report on MSUS findings– In-depth discussion 1 – Module 1

linked controls. However, these wall filters also remove slow flow as the Doppler shift from noise and the
Doppler shifts from slow flow are very similar.

Selecting a high PRF therefore makes the system insensitive to lower velocities because of the linked controls.
A high PRF in colour Doppler will show correct information about direction and velocity at the expense of flow
information and in power Doppler there is no direction of velocity information but high PRF here will also
eliminate slow flow because of the wall filters. In rheumatology, we wish a high sensitivity to any flow and
therefore use a low PRF because the machine then will apply the lowest possible filters. As the PRF and wall
filter are linked controls—the lowest possible wall filter is lower for a low PRF than for a high PRF. The filters
should be kept at their lowest setting for use in rheumatology.

The impact on flow can be seen in film clip 4a and 4b and 4 c. – go to images section.

4. Gain

The Doppler gain is independent of grey-scale gain. The gain settings determine the sensitivity of the system to
flow. The correct way to adjust the Doppler gain is by turning it up until random noise is seen and then
lowering it until the noise disappears.

(film clip 5a and 5 b – go to images section)

5. Colour priority/threshold

When colour information is obtained, grey-scale information will also be present and the machine has to
determine whether to show one or the other. The setting of colour priority determines what is the most
important to be shown in the image. This function is available for the examiner to adjust on some machines -
on others you will need help from the product specialist to be able to adjust it.

A low colour priority/threshold setting will allow valid grey-scale information to override false Doppler
information, eg, it helps suppress motion artefacts in the relatively hyperechoic tissue surrounding a pulsating
artery (above a certain grey level, grey overrides colour) but at the same time it will also allow grey colours to
override true slow flow which has the same Doppler shifts. It will then only show flow in the darkest areas in
the image – the big vessels (e.g. arterial flow). A high colour priority/threshold setting will allow the machine
to let colour information override the grey-scale information showing flow in vessels that cannot be seen with
the eye. As this is frequently the case in rheumatology (fx synovial flow), colour priority must be maximised (be
set so that grey does not override colour information) as not to lose flow information.(film clip 6 a and 6b – go
to images section)

©2007-2015EULAR 4
 B-mode MSUS and Doppler MSUS physics; indications and limits of MSUS; normal findings and basic abnormalities;
artefacts; image documentations; how to write a report on MSUS findings– In-depth discussion 1 – Module 1

6. Other important issues

Apart from the settings transducer pressure may influence the flow. By applying pressure on the probe during
examination the vessels may be compressed and flow information will be lost. (Figure 7a and 7b).

Position of the joint may also influence detection of Doppler signal in the examined structures (ref. 1).

Increasing the size of the Doppler box decreases the frame rate thus also decreasing the sensitivity of flow
detection.

Finally, focus position is as important in Doppler as in grey scale US, increasing Doppler sensitivity in the focal
zone (film clip 8 a and 8b – go to images section).

Summary:

Adjusting and optimizing the Doppler settings correctly will have great impact on the ability to detect
inflammatory flow. Recent findings indicate that flow information can be increased up to 156% just by
adjusting the Doppler correctly which will have a huge impact on the scoring of inflammatory findings (ref.2).

Once the Doppler has been adjusted remember to save the settings so that you do not have to adjust them
every time. Always use the same settings for follow-up examinations in order for the results to be comparable
in your patients.

©2007-2015EULAR 5
 B-mode MSUS and Doppler MSUS physics; indications and limits of MSUS; normal findings and basic abnormalities;
artefacts; image documentations; how to write a report on MSUS findings– In-depth discussion 1 – Module 1

Figure 7. Transducer pressure

Table 1

Function Adjustment
Doppler frequency Lowest or highest depending on machine

PRF Lowest possible*

Wall filter Lowest possible*

Colour priority All priority to colour

Gain On the threshold to noise

Focus Where the highest detection sensitivity is required

Size of the box As small as possible reaching the top of the image
*Lowest possible where motion artefacts are avoided most of the time.

©2007-2015EULAR 6
 B-mode MSUS and Doppler MSUS physics; indications and limits of MSUS; normal findings and basic abnormalities;
artefacts; image documentations; how to write a report on MSUS findings– In-depth discussion 1 – Module 1

Reference:

1. Zayat AS1, Freeston JE, Conaghan PG, Hensor EM, Emery P, Wakefield RJ. Does joint position affect US
findings in inflammatory arthritis? Rheumatology (Oxford). 2012 May;51(5):921-5.

2. Torp-Pedersen S, Christensen R, Szkudlarek M, Ellegaard K, D'Agostino MA, Iagnocco A, Naredo E,

Balint P, Wakefield RJ, Torp-Pedersen A, Terslev L. Power and color Doppler ultrasound settings for
inflammatory flow: impact on scoring of disease activity in patients with rheumatoid arthritis.Arthritis
Rheumatol. 2015 Feb;67(2):386-95.

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