Ultrasound

(1) Principle of Ultrasound

The limits of human hearing cover the range from about 20 Hz to 20000 Hz. Vibrations with
frequencies higher than 20000 Hz are termed Ultrasonic. The ultrasonic beams used in
diagnostic imaging have frequencies ranging from 1 MHz – 20 MHz.
A sound beam is similar to an X-ray beam in that both are waves transmitting energy. However,
X-rays passes readily through a vacuum whereas sound requires a medium for its transmission.
The velocity of sound depends on the nature of the medium. The important characteristics of the
transmitting medium are (1) its compressibility, and (2) density. On an average, sound travels
slowest in gases, at intermediate velocity in liquids, and most rapidly in solids. All body tissues,
except bone, behave like liquids, and therefore, they all transmit sound at about the same
velocity. A velocity of 1540 m/s is used as an average for body tissues.
The relationship between wavelength and wave velocity is as follows:
V = frequency x wavelength
In the ultrasonic frequency range, the velocity of sound is constant in any particular medium;
when the frequency is increased, the wavelength must decrease.

Interactions between ultrasound and matter

The types of interactions between sound and matter include (a) Reflection, (b) Refractions and
(c) Absorption.

a. Reflection
The percentage of the beam reflected at tissue interfaces depends on (i) the tissues acoustic
impedance and (ii) the beam’s angle of incidence.

(i) Acoustic impedance

The impedance of a material is the product of its density and the velocity of sound in the
material.
Different body structure in order of decreasing acoustic impedance are: Air, Fat, Water, Brain,
Blood, Kidney, Liver, Muscle, Lens of eye, Bone.
As sound waves pass from one tissue plane to another, the amount of reflection is determined by
the difference in the impedances of the two tissues. The greater the difference, the greater the
percentage reflected. At a tissue-air interface, more than 99.9% of the beam is reflected, so none
is available for further imaging. Transducers, therefore, must be directly coupled to the patient’s
skin without an air gap. Coupling is accomplished by use of a slippery material such as mineral
oil for contact scanning or by a water bath when the transducer cannot be placed directly on the
patient.

(ii) Angle of incidence

The amount of reflection is determined by the angle of incidence between the sound beam and
the reflecting surface. The higher the angle of incidence, the less the amount of reflected sound.
The angles of incidence and reflection are equal. In medical ultrasound, in which the same
transducer both transmits and receives ultrasound, almost no reflected sound will be detected if
the ultrasound strikes the patients surface at an angle of more than 3 degrees from perpendicular.

b. Refraction
The binding of waves as they pass from one medium to another is called refraction. Refraction
can cause artifacts. Refractions artifacts cause spatial distortion (real structures are imaged in the
wrong location) and loss of resolution in the image.

Artifacts
While some ultrasound artifacts can lead to mis-diagnosis, other artifacts can aid diagnosis, since
they often given information about tissue characteristics. The artifacts that aid in diagnosis are
enhancement and shadowing behind lesions.

(i) Posterior shadowing

When the lesion becomes denser or even calcified the impedance difference between the
surrounding tissue and the mass increases. Reflection also contributes to attenuation and
produces a posterior shadow. Sometimes ultrasound transmitted into the mass will be reflected
off the back wall of the mass and will be imaged as a reverberation shadow.
Shadows also occur when the ultrasound beam encounters air in the body. These shadows are the
result of the large impedance mismatch between tissue and air.
Shadows occurring from the skin are due to scars or poor application of coupling gel. Air is
trapped between the transducer and skin causes shadowing.

(ii) Posterior enhancement

Posterior enhancement behind less attenuating tissue is also used diagnostically to differentiate
solid from fluid filled masses. Cysts, hematomas, and abscesses all show posterior enhancement.
In the breast, some solid lesions, such as fibro adenoma and medullary carcinoma, may show
posterior enhancement because they are less attenuating than the tissue surrounding them.

(iii) Anechoic masses

Masses are assumed to be solid if they have internal echoes on US images and show no posterior
enhancement. Sonolucent masses only indicate a homogenous internal structure and do not
indicate cysts. In order to determine whether the mass is solid or fluid, it is necessary to evaluate
the echoes deep to the mass. If enhancement is present, the mass is cystic.
Occasionally we may see echoes within a mass that are artifacts. These echoes occur if the gain
or power is too high. In particular, obstetric scanning with full bladder may show echoes in the
anterior portion of the bladder when the gain is too high.

(iv) Beam thickness artifact

Ring down artifact occurs when sound waves encounters a dense object e.g. cholesterol crystal or
gas. Most of it is reflected but those that enter tend to be reflected back and forth within the
object. Since lateral resolution is usually no better than 3 mm even in the focal zone, a point
target in the far field will look like a line with thickening in the center. This is why all
measurements should be made in the axial direction rather than in the lateral direction.

(v) Ghost artifact/split image artifact

This arises due to the presence of extra peritoneal fat deep to the linea alba and rectus abdominis
muscle. The effect is usually commonly when the collection of fat beneath the linea alba is large
and the structure of interest is deep below the abdomen wall.

c. Absorption
The term absorption refers to the conversion of ultrasonic energy to thermal energy and
attenuation refers to total propagation loss, including absorption, scattering and reflection.
Three factors determine the amount of absorption: (i) the frequency of sound, (ii) the viscosity of
the conducting medium, and (iii) the relaxation time of the medium.
In liquids, which have low viscosity, very little absorption takes place. In soft tissues viscosity is
higher and a medium amount of absorption occurs, whereas bone shows high absorption of
ultrasound.
The relaxation time is the time that it takes for a molecule to return to its original position after it
has been displaced.
In soft tissues there is a linear relationship between absorption of ultrasound and frequency.
Doubling the frequency approximately doubles absorption. The proper frequency is a
compromise between the best resolution (higher frequency) and the ability to propagate the
energy into the tissues (lower frequency).

(2) Types of Ultrasound

(a) Abdominal Ultrasound Imaging
Because US images are captured in real time, they can show movement of internal tissues and
organs and enable physicians to see blood flow. This can help to diagnose a variety of conditions
and to assess damage caused by illness.
Ultrasound imaging is used extensively for evaluating the kidneys, liver, gallbladder, pancreas,
spleen, and blood vessels of the abdomen. Because it provides real-time images, it can also be
used to:
 Guide procedures such as needle biopsies, in which needles are used to sample cells from
organs for laboratory testing.
 Help a physician determine the source of many abdominal pains, such as stones in the
gallbladder or kidney, or an inflamed appendix.
 Help identify the cause for enlargement of an abdominal organ.
 Doppler ultrasound is a special type of ultrasound study that examines major blood
vessels. These images can help the physician to see and evaluate:
 Blockages to blood flow, such as clots.
 Build-up of plaque inside the vessel.
 Congenital malformation.
 With knowledge about the speed and volume of blood flow gained from an ultrasound
image, the physician can often determine whether a patient is a good candidate for a
procedure like angioplasty.
The patient is positioned on an examination table, and a clear gel is applied to the abdomen to
help the transducer make secure contact with the skin. The sound waves produced by the
transducer cannot penetrate air, so the gel helps to eliminate air pockets between the transducer
and the skin. The sonographer or radiologist then presses the transducer firmly against the skin
and sweeps it back and forth to image the area of interest.
When the examination is complete, the patient may be asked to dress and wait while the
ultrasound images are reviewed, either on film or on a monitor. The examination usually takes
less than 30 minutes.
(b) Pelvic Ultrasound Imaging
Pelvic ultrasound is most often used to examine the uterus and ovaries and, during pregnancy, to
monitor the health and development of the embryo or fetus. In men, a pelvic ultrasound usually
focuses on the bladder and the prostate gland.
For women, ultrasound examinations can help determine the causes of pelvic pain, abnormal
bleeding, or other menstrual problems. Ultrasound images can also help to identify palpable
masses such as ovarian cysts and uterine fibroids, as well as ovarian or uterine cancers.
Sonohysterography (saline infusion sonography) is a procedure in which sterile saline is injected
into the uterus while a transvaginal sonogram is performed. The purpose is to distend the uterine
cavity (endometrial cavity) to look for polyps, fibroids, or cancer, especially in patients with
abnormal uterine bleeding. The saline outlines the lesion and allows for easy visualization and
measurement. Some physicians also use sonohysterography for patients with infertility. Saline
and air are injected into the uterus and the physician looks for air bubbles passing through the
fallopian tubes, which would indicate patency of the fallopian tubes.
In men, pelvic ultrasound is a valuable tool for evaluating the prostate gland, as well as for
evaluating the seminal vesicles.
A pelvic ultrasound exam can help to identify stones, tumors and other disorders in the urinary
bladder in both men and women. There are three methods of performing pelvic ultrasound:
abdominal (transabdominal), vaginal (transvaginal, endovaginal) in women, and rectal
(transrectal) in men.
 Transabdominal
For the transabdominal approach, the patient has a full urinary bladder and is positioned on an
examination table. A clear gel is applied to the lower abdomen to help the transducer make
secure contact with the skin.
 Transvaginal
Transvaginal ultrasound involves the insertion of the transducer into the vagina after the patient
empties her bladder and is performed very much like a gynecologic exam. The tip of the
transducer is smaller than the standard speculum used when performing a Pap test. A protective
cover is placed over the transducer, lubricated with a small amount of gel, and then inserted into
the vagina. Only two to three inches of the transducer end are inserted into the vagina. The
images are obtained from different orientations to get the best views of the uterus and ovaries.
 Transrectal
The prostate gland is located directly in front of the rectum, so the ultrasound exam is performed
transrectally. A protective cover is placed over the transducer, lubricated, and then placed into
the rectum so the sound need only travel a short distance. The images are obtained from different
orientations to get the best view of the prostate gland. Ultrasound of the prostate is most often
performed with the patient lying with his left side down on the table and with his knees bent up
slightly toward the chest.
If a suspicious lesion is identified with a rectal examination, an ultrasound-guided biopsy can be
performed. This procedure involves advancing a needle into the prostate gland while the
radiologist watches the needle placement with ultrasound. A small amount of tissue is taken for
microscopic examination.
(c) Obstetric Ultrasound Imaging
Obstetric ultrasound refers to the specialized use of sound waves to visualize and thus determine
the condition of a pregnant woman and her embryo or fetus.
Obstetric ultrasound should be performed only when clinically indicated. Some indications may
be:
 To establish the presence of a living embryo/fetus.
 To estimate the age of the pregnancy.
 To diagnose congenital abnormalities.
 To evaluate the position of the fetus.
 To evaluate the position of the placenta.
 To determine if there are multiple pregnancies.
Sometimes the radiologist determines that a transvaginal scan will need to be performed. Instead
of a transducer being moved over your abdomen, the high-frequency waves will be emitted by a
transducer placed in the vagina. This technique often provides improved, more detailed images
of the uterus and ovaries. It is especially useful in early pregnancy.
The obstetric ultrasound examination takes about 20 minutes.
(d) Carotid and Abdominal Aorta Ultrasound Imaging
Ultrasound of the carotid arterial system provides a fast, noninvasive means of identifying
blockages of blood flow in the neck arteries to the brain that might produce a stroke or mini-
stroke. Ultrasound of the abdominal aorta is primarily used to evaluate for an aneurysm which is
an abnormal enlargement of the aorta usually from atherosclerotic disease.

(3) Description of Equipment

Most equipment contains the same basic building block circuits: transmitter, receiver, display
and scan converter.
(a) Transmitter
The transmitter circuit produces either a high amplitude, short duration voltage shock pulse or a
driving voltage waveform. Then on Output Control attenuates the amplitude of this voltage
before it is applied to the transducer.
(b) Receiver
After the received echoes are converted into weak voltage waveforms by the transducer, they are
processed by the receiver. The receiver is made up of many sub-blocks or circuits, each one
performing a specific signal processing function.
The first sub-block is the Limiter. Its function is to protect the rest of the receiver from the high
transmitter voltages.
The next sub-block is the Log Amplifier that amplifies the weak echo signals.
Next, the echo signals enter the Rectifier sub-block where the negative half cycles in the echo
voltage waveforms are converted into positive half cycles.
Then, with Demodulation, the fundamental frequency signal on which the echo amplitude
information has been riding is eliminated leaving the so called envelope of the echo signal. The
demodulator circuit is really just a smoothing circuit that can only respond to the envelope of the
pulse and to the oscillations at the transducer center frequency.
(c) Scan converter
The received echoes are stored in a scan converter (which stores both echo position and
amplitude information) and then passed on to the display for viewing and hardcopy generation.
(d) Display
Cathode ray tubes or broadcast TV tubes are used as the display in most ultrasonic images. The
face of the CRT is a 2 dimensional surface that can display the echo data in a 2 dimensional
format.
Transducers
A transducer is a device that can convert one form of energy into another. Ultrasonic energy that
can be transmitted into tissues, and to convert ultrasonic energy reflected back from the tissues
into an electric signal.
Diagnostic ultrasonic transducers make use of certain naturally occurring and artificially
produced substances with Piezo electric properties.
Piezo electricity = Pressure electricity

In 1880 Pierre and Jacques Curie first observed the piezoelectric property in quartz, Rochelle
salt, and tourmaline. They applied a weight to a crystal and found that a charge was generated in
the crystal. The charge was generated because these crystals were anisotropic rather than
isotropic.
Certain materials are such that the application of an electric field causes a change in their
physical dimensions and vice versa. This is called the piezoelectric effect.
Piezoelectric effect: When transducer is acting in receiving mode.
Reverse P.E.: When transducer is acting in the transmitter mode.
The Piezoelectric Element
A piezoelectric material, is an element that generates electricity when pressure is applied to it
and that changes shape when electricity is applied to it. The piezoelectric material is the material
that produces diagnostic ultrasound. Piezoelectric materials may be man-made or naturally
occurring, such as quartz and tourmaline. The piezoelectric material that is commonly used in
current ultrasound transducers is a man-made ceramic called lead zirconate titanate (PZT). The
PZT is the actual transducer inside the scanhead. It may also be referred to as the crystal, the
element, or simply, the transducer. Emerging technology for transducer material includes
silicon-based capacitive micromachined ultrasound transducers (CMUT), polyvinylidene
fluoride (PVDF), and single crystal technology.
Man-made piezoelectric materials like PZT must undergo a process to obtain their piezoelectric
properties. First, the PZT is placed into an oven that is used to heat the material to the Curie
point. The Curie point, which is around 328° to 365° C, is the temperature at which the material
will obtain piezoelectric properties. While being heated, the PZT is placed into a magnetic field.
This causes magnetically charged molecules, which are located within the material and referred
to as dipoles, to align themselves in relation to the magnetic field. Once the material is cooled, it
is functional as a piezoelectric element. Unfortunately, once a ceramic is taken to its Curie point,
it must never return to that temperature again or the material will lose its piezoelectric properties
forever. For this reason, ultrasound transducers are never heat sterilized.
When high-level disinfection is necessary, transducers must be cold sterilized using either a
glutaraldehyde solution, such as Cidex or Metricide, or a non-glutaraldehyde-based solution,
such as ortho-phthalaldehyde. Cold-sterilizing solutions can be dangerous if they get in the eyes,
on the skin, or are inhaled. Personal protective equipment must be worn while handling these
solutions. Sonographers should be familiar with the appropriate safety data sheets for these
solutions. A newer method of endocavitary transducer high-level disinfection utilizes a warmed
hydrogen peroxide solution to disinfect transducers.
Real-time Scanning
Modern ultrasound equipment utilizes real-time, or automatic scanning, to obtain diagnostic
images of the body. With real-time scanning, the transducer is responsible for sending out scan
lines across a defined plane. Images are produced when an ultrasound beam is swept across that
plane. For the sonographer, real-time imaging offers the ability to instantly view internal
structures of the body. Pulses of ultrasound are sent out and produce scan lines. All of the scan
lines, when placed next to each other, form an image that is called a frame.
Types of Transducers
There are two methods of sending out scan lines to form an image using real time: mechanical
scanning (via mechanical transducers) and electronic scanning (via electronic transducers). Both
methods provide a means for sweeping the ultrasound beam through the tissue repeatedly and
rapidly. Although electronic scanning is most often the method employed today.
 (a) Mechanical Transducers
These transducers typically had one or more piezoelectric elements connected to a motor, or a
fixed element with a mirror connected to a motor. The motor, or a mirror, steered the element to
produce the scan lines that made up the image. This produced a sector image pattern. The
piezoelectric element and motor were inside of a protective housing. Oil was used as a coupling
medium to prevent air from forming within the housing. Air within the housing would hamper
the transmission of the sound. These transducers were fixed frequency and fixed focus. That is,
in order to change the frequency or the location of the focal zone, one had to change the entire
scanhead. Focusing of the beam was achieved by either the shape of the element or the use of a
lens. The major advantages of the mechanical transducer
were that they were inexpensive and typically had a small footprint. These transducers were
fragile and their mechanical elements were easily broken. Today's modern-day equivalent
version of mechanical transducers are three- and four-dimensional transducers. These
transducers consist of an entire array transducer mounted to a motor and enclosed within a
housing. Some similar specialty transducers, like endorectal and intravascular transducers, also
use a single element mounted on a motor.
(b) Electronic Transducers
Electronic scanning is performed with transducers that have multiple active elements. This is
referred to as an array. An array is formed by taking a single slab of PZT and slicing it down
into multiple subelements. Each subelement is connected to a wire, so it may fire independently.
The system can selectively excite the elements as needed to shape and steer the beam. With most
array transducers, no motors are needed for beam steering. Arrays may be either sequenced or
phased and can produce various image shapes.
Linear Sequenced Array
The linear sequenced array, also referred to as the linear sequential array or linear array, is a
transducer that is often used in vascular or high-resolution imaging. This transducer produces a
rectangular-shaped image. With the linear sequenced array, the elements are arranged in a line,
next to each other, but are fired in small groups in sequence. For example, the elements are not
fired 1-2-3-4-5 but are fired (1-2-3) . . . (4-5-6) ... (7-8-9).
Curved Sequenced Array
The curved sequenced array transducer, also referred to as a convex, curvilinear, or curved
sequential array, is based on the same technology as that of the linear sequenced array but with a
curved face. As with the linear sequenced array, the elements are fired in groups.
Phased Arrays
The phased array is more commonly known as a sector or vector transducer. The sector/vector
transducer typically has a small footprint, also referred to as the "face" of the transducer, and it
may be used for cardiac imaging, neonatal brain imaging, with some endocavitary transducers,
and any other application where a sector or vector image shape is desired.
(c) Three-Dimensional Transducers
Three-dimensional (3D) ultrasound images are traditionally made up of two-dimensional (2D)
acquisitions placed next to each other. A 3D image allows the user to see width, height, and
depth. It may also be referred to as volume scanning. There are three different ways to create the
3D image: freehand, with a mechanical transducer, or the newest method, electronically, with the
latest 2D array technology. In the freehand method, also referred to as manual, the sonographer
is responsible for moving the transducer through a path to gather the 2D slices. This method is
the most operator dependent, as it relies upon the steady hand of the sonographer to move the
transducer at the same speed over the tissue. Because of the potential variability in movement
across the plane, measurements of the 3D image are not possible with freehand 3D technique.
The 2D slices, once converted to 3D format, may then be sliced to view coronal, sagittal, and
axial planes. With the mechanical technique, also referred to as automated or mechanical
3D method, specialized transducers have been developed that are essentially curved sequenced
array transducers mounted onto a motor. These transducers permit measurement on the screen of
the 3D image as well as the use of real-time 3D, also known as four-dimensional (4D)
ultrasound.
The frame rate of the 4D image is limited by the speed of the motor to which the transducer is
attached. The latest technology for acquiring a 3D image is the new electronic array, called a 2D,
array, or matrix array transducer. These transducers acquire real-time volumes using
transducers with up to 10,000 elements compared to the 128 to 512 elements used in standard 1D
array transducers.
(d) Continuous-Wave Transducers
CW transducers are utilized as part of Doppler studies. A dedicated CW transducer contains two
piezoelectric elements: one to continuously transmit sound and one to continuously receive
sound. No image is generated with these transducers, because it is not possible to time how long
it takes the echoes to return. Therefore, CW transducers have no range resolution (i.e., they
have depth ambiguity).
(4) Indication and Clinical Applications
Indications for Ultrasound Use
Ultrasound usually works best in thinner individuals, since the transducer is closer to the imaged
structures in those patients. For larger patients, ultrasound can be limited. Ultrasound is
particularly useful in evaluation of the upper abdomen, female pelvis organs, and superficial
structures like the thyroid, breast, and scrotum. Ultrasound can also be used to guide the
placement of needles into structures during biopsy or fine needle aspiration. It allows one to see
the needle moving in real time as it enters the target, whereas in CT-guided biopsies, the images
are obtained after the needle has been advanced into the organ/mass.
Since ultrasound does not use ionizing radiation, it is one of the safest imaging modalities for
women of reproductive age and young children. It is ideal for prenatal imaging.
Ultrasound is least useful in the chest since air in the lung is a relatively poor transmitter of
sound. For this reason, ultrasound also does not work well in patients with large amounts of
bowel gas. It is also of limited use in the head since the dense bony skull is a poor transmitter of
sound, primarily reflecting it. However, ultrasound can be used to examine the brains of infants
since access to the intracranial structures can be achieved through the open fontanels.
Biological effects and safety mechanisms
Heating and cavitation are known mechanisms of action by which US could produce biological
effects in tissues. Other mechanisms may exist but have not been identified.
Attenuation in tissues is primarily due to absorption that, is conversion of US to heat. The
heating produced depends on the applied intensity and frequency of sound. Heating could only
be a relevant mechanism for in vivo-biologic effect at intensities above approx. 100 mW/cm² at
diagnostic frequencies. Therefore, for common imaging situation, heating is probably not a
relevant mechanism. Cavitation is the production and motion of bubbles in a liquid medium. It
can be caused by a propagating sound wave. Two types of cavitation are recognized to occur.
Stable cavitation is the term used to describe bubbles which oscillate in diameter with the
passing pressure variations of the sound wave. Streaming of surrounding liquid can occur in this
situation and result in shear stresses on suspended cells or intracellular organelles. Transient
cavitation occurs when bubble oscillations are so large that the bubble collapses, producing
shock waves and localized extremely high temperatures which have the potential for significant
destruction effects.
Risk and benefit
Information from in vitro (sister chromatid exchange having been studied maximum) and in vitro
experimental studies and from epidemiology has yielded no known risk in the use of ultrasound
in medical imaging.
According to AIUM:
 In the low MHz frequency range there have been no independently confirmed significant
biological effect in mammalian tissue exposed in vivo to unfocussed US with intensities
below 1 w/cm². Furthermore, for exposure time is and 500 s for unfocused US or 50 s for
focused US, such effects have not been demonstrated even at higher intensities, when the
product of intensity and exposure time is less than 50 joules/cm².
 Based solely on a thermal criterion, a diagnostic exposure that produces a maximum
temperature rise of 1°C above normal physiological levels may be used without
reservation in clinical examinations.
 As in situ temperature rise to or above 41°C is considered hazardous in fetal exposures,
the longer this temperature elevation is maintained, the greater the likelihood for damage.
Absorption coefficients are higher in bone than in superficial tissue. Bone heating
especially in fetus should therefore receive special consideration.
Given, its known benefits and recognized efficiency for medical diagnosis, including use in
human pregnancy AIUM addresses the clinical safety of diagnostic US for such use as ‘No
confirmed biological effects on patients or instrument operators caused by exposure at intensities
typical of present diagnostic US equipment have ever been reported. Although the possibility
exists that such biological effects may be identified in the future, current data indicate that the
benefits to patients of the prudent use of diagnostic US outweigh the risks, if any, that may be
present.
Prudent Use
US imaging should be used when medically indicated with minimum exposure. Minimized by
minimizing both instrument output and exposure time.