BASICS OF

ULTRASOUND

Dr Sabin Bhandari
Junior Resident
Dr Asish Subedi
Moderator
 It is not a bad definition of man to describe
him as a tool-making animal.
Charles Babbage (1791 1871)
 Why This is Important

Ultrasound is already here and certain

experts are proclaiming that its use should
be standard of care.
 Introduction to sound and ultrasound
Sound waves are a type
of mechanical vibration
that is transmitted in a
medium (e.g. air), that
can be heard by an
human ear.

Sound specifically refers

to what the human ear
can hear.
The characteristics of
sound waves are
1. wavelength:
Wavelength is the
distance between
identical points in
adjacent cycles of a
waveform.
2. amplitude: measured
in decibels (dB);
3. period: the time it
takes for one cycle to
occur, measured in
seconds.
 Sound waves are
described in terms of
their frequency, which is
the number of repetitions
(ie, cycles) per second.

The unit for measuring

frequency is the Hertz
(Hz) and can be thought
of as vibrations per
second (this not the
official definition!).
 Relationship between Wavelength &
Frequency

The high frequency wave has more cycles that are

squeezed into the one second time frame.

The low frequency wave has less cycles squeezed

into the same one second time frame.

Thus the cycles in a low frequency wave are more

more wide apart.
 The human ear cannot
hear below 20 Hz and Sound
frequencies below this
are called infra sound.
Elephants

The human ear cannot

hear above 20,000 Hz.
Frequencies above
20,000 Hz are called
ultrasound.
Bats and dolphins
 The speed of sound varies Medium Ultrasound
for different biological Speed (m/sec)
media but the average Air 300
value is assumed to be Lung 500
1,540 m/sec (constant) for Fat 1450
most human soft tissues. Brain 1520
Muscle 1580

The speed of sound (c) Liver 1550

can be calculated by, Kidney 1560

c = wavelength () x Blood 1560

frequency (f). Soft tissue 1540
B0ne 4000
To use ultrasound to
find things, one needs
something to create
vibrations that will
travel in the tissues in
a patient.

One needs to have a

way of listening to the
sound waves that are
bounced off various
objects
 Generation of Ultrasound Waves
Generated by piezo
electric crystal.

When a voltage is Piezo electric

applied to an piezo crystal

electric crystal (shown

in red), it expands.

When the voltage is

removed, it contracts
back into its original
thickness.
 If the voltage is
rapidly applied and
removed
repeatedly, the
piezo electric
crystal rapidly
expands and
relaxes, creating
ultrasound waves.
 Receiving Ultrasound
Piezo electric crystals have another very useful
property that enables it to be also used for
receiving ultrasound waves.

When a piezo electric crystal is compressed, it

generates a voltage.

This property is used to listen for the ultrasound

waves that return after striking objects.
First the machine The ultrasound machine
applies a voltage to the then very quickly
crystal to expand it and switches to a listening
transmit ultrasound mode.
waves. The returning waves
compress the crystal
thereby producing
voltage.
 The information
gathered from the
crystals are processed
by a computer to
display the images on
a screen.
Most ultrasound machines have the following
components in common:
1. Pulser (transmitter): generates pulsed echo in
brief bursts

2. Transducer: converts electrical energy to acoustic

pulses and vice versa

3. Receiver: which detects, compresses and

amplifies signals returning to the transducer

4. Display: which displays the signal

5. Memory: which stores still and video images

 INTERACTION OF ULTRASOUND
WAVES WITH TISSUES
When an ultrasonic wave
travels through a
homogeneous medium,
its path is a straight line.

When the medium is not

homogeneous or when
the wave travels through
a medium with two or
more interfaces, its path
is altered.
What happens to the ultrasound waves
?
The relationship between ultrasound waves and
tissues can be described in terms of

Attenuation,

Scattering,

Reflection, and

Refraction
 Attenuation

During transmission,
ultrasound signal strength
is progressively reduced
due to absorption of the
ultrasound energy by
conversion to heat, a
process called
attenuation.

These waves dont return to

the probe and are therefore
wasted.
 Attenuation is measured
in decibels per
centimeter of tissue and
is represented by the
specific tissue type.

The higher the

attenuation coefficient,
the more severely is the
beam transmission
limited.
 Attenuation is frequency
and wavelength
dependent.

The depth of penetration

is limited to approximately
200 wavelengths,
corresponding to a depth
of
30 cm for a 1 MHz
transducer,
12 cm for 2.5 MHz
transducer, and
6 cm for a 5 MHz
transducer
 Attenuation is also
dependent upon
acoustic impedance
and any mismatch in
impedance between
adjacent structures.

Acoustic impedance is the

resistance of a tissue to a
passage of ultrasound.
 Resistance=pressure diff
flow
Acoustic impedance, Z
= pressure
flow
Acoustic impedance, Z
= tissue
density x propagation
velocity

The SI unit is Pascal

second per cubic meter
or rayl per square meter.
 When an ultrasound wave
tries to pass from one
substance to another with
a different acoustic
impedance, two things
happen to it.

Part of the ultrasound

waves continues into the
second substance, but
becomes slightly bent Part of the wave is
away from their original reflected back to the
direction which is called probe.
refraction.
 Reflected waves are the only waves that return back to
the probe and provide information for the machine to
show an image.

If there is a small bubble of air between the probe and

the patients skin, the ultrasound waves will be
reflected away instead of penetrating the skin hence
no image is obtained.
 To minimize the
difference in impedance,
if a thick liquid ( jelly ) is
used between the probe
and the patients skin, it
results in easy passage
of the ultrasound waves.
 Every substance , such
as a nerves, muscles, or
fat, has an acoustic
impedance.

As the ultrasound wave

crosses from one tissue
to the next, some of the
wave is reflected back at
each crossing (two blue
arrows in the image).
 Multiple reflected
waves return to the
probe and the
machine uses this
information to display
an image showing the
different tissues.
 Irregular surfaced objects
such as nerves scatter
the ultrasound waves in
all directions.

A small portion of the

waves are reflected back
to the probe which is
called scattered
reflection.
 If an object is large and
smooth like a nerve
blocking needle, all the
ultrasound wave is
reflected back.

This mirror like reflection,

where the waves are
reflected back mostly in
one direction is called
specular reflection.
Ultrasound Wave Interaction with Tissues
Reflection
SPECULAR (large
smooth objects like
a needle) (d)

SCATTERING (most
neural images) (a)

Refraction (c)

Transmission (b)
 Tissue echogenicity

When an echo returns to

the transducer, its
amplitude is represented
by the degree of
brightness (i.e.,
echogenicity) of the dot
on display.

Combination of all the

dots forms the final
image.
 Larger intensities =
Strongly reflected =
Hyperechoic image (Whiter)

Weaker intensities =
Weakly Reflected =
Hypoechoic (Darker)
Tissues Ultrasound inage for RA

Veins Anechoic (compressible)

Arteries Anechoic (incompressible)

Fat Hypoechoic with irregular

hyperechoic lines

Muscles Heterogenous (mixture of

hyperechoic lines within a
hypoechoic tissue
background)
Tendons Predominantly hyperechoic

Bones Hyperechoic lines with a

hypoechoic shadow

Nerves Hyper / hypo echoic

 A nerve (arrowhead, N) and a tendon (arrow, T) of
the forearm in cross section.

The nerve is oval and the tendon has an irregular

shape.

Tendon will merge into a muscle while a nerve

does not.
Nerve consists of continuous hypoechoic
longitudinal elements interspersed with hyperechoic
perineural connective tissues.

Tendons has continuous fibrillar echotexture and

discontinuous hyperechoic speckles.
 Nerves are generally hypoechoic in the
interscalene and supraclavicular region.

The hypoechoic component represents the neural

tissue.
 Nerves below the clavicle and in the lower limbs
are predominantly hyperechoic and have a
honeycomb appearance.

The degree of hyperechogenicity likely represents

the amount of connective tissues within the nerve.
 Display

There are many different ways a ultrasound probe

can look at things. These ways are called
modes.

A mode (Amplitude mode)

B mode (Brightness mode) including real time, 2

dimensional, B mode

M mode (Motion mode)

 A-mode (Amplitude modulation)

The A mode is the simplest form of ultrasound

imaging and is not frequently used.

The returning echo causes a vertical deflection

whose amplitude is used to calculate the depth of
the interface.

As an example, ophthalmologists may use it for

determining the thickness of the cornea.
 The ultrasound wave that comes out of the probe
travels in a narrow pencil like straight path.

An ultrasound wave is sent from the probe and at

the same instance, a line from the left of the
screen starts to be drawn.

This line moves horizontally measuring time.

 As the wave reaches the first wall of the eye, some
of the ultrasound is reflected back into the probe.

The returned wave is recorded on the line as a

bump.

The height of the bump is called Amplitude which

is what the A of A scan stands for.
 The wave then meets the wall that is furthest
away.

Again some of the ultrasound wave is reflected

back into the probe and another bump is drawn.

The time difference between the first bump and the

second bump represents how long the ultrasound
wave took to travel between the two walls thus
giving the length of eyeball.
 B-mode (Brightness modulation)
The B scan mode is very similar to the A scan
mode.

Using the eye ball as an example, a wave of

ultrasound is sent out in a pencil like narrow path.

When the wave meets the first wall, a part of the

wave is reflected back into the probe which is
recorded by a bright dot instead of a bump.
 When the wave reaches the other wall, part of it is
reflected back into the probe which is again
represented as a bright dot or pixels on the screen.

The first B scan line is kept on the screen and the B

scan is repeated at slightly different levels starting
from top to bottom of the eyeball.
 In real life, the process happens very quickly and
the structures are scanned and the image redrawn
many times a second.

In this way, a two dimensional (2 D) image of the

object is formed on the screen.
 Since the image is redrawn so rapidly, one can
see size changes (e.g. pulsations of carotid artery)
in real time (i.e. as it happens) if the frame rates
are of at least 15 per second.

Hence, the complete description of the mode is

real time , 2 dimensional (2 D), B scan.
 M-mode (Motion modulation)
M-mode imaging is B-mode with a continuous
update of the returning echoes.

This forms a sequence of B-mode that shows

changes over time.

A single crystal rapidly alternates between

transmission and receiver modes with rapid
updating (>1000 Hz)

rapidly moving structures (e.g., valve leaflets) can be

monitored for their characteristic motion.
 In the M-mode, a single beam of ultrasound is
transmitted and structures along the path reflects
sound back to the transducer.

Here, the bottom scatterer is moving.

If the depth is shown in a time plot, the motion is

seen as a curve.
 A diagrammatic
representation of M-mode
echocardiographic
examination of the heart
in the parasternal long
axis position.

The transducer (T) sits on

the anterior chest wall in
the precordial parasternal
window and the beam is
swept from apex to base.

Ao: aorta; LA: left atrium; LV: left

ventricle; MV: mitral valve; P:
pericardium; PE: pericardial effusion;
RV: right ventricle; Ant RVW: anterior
RV wall; Post LVW: posterior LV wall.
 Resolution

Resolution is the ability to see two things as two

things.

If the resolution is good, the picture will be clear

and the two objects will look like two objects and if
it is poor, the picture will be blurred and the two
objects will look like one.
 It varies directly with the frequency and inversely
with the wavelength

If two separate structures are closer than one

wavelength apart, then they will not be identified
as separate.

Therefore, smaller wavelengths are associated

with improved resolution.
 So to get a good resolution, a high frequency
should be used because a high frequency has a
short wavelength. i.e. high frequency = short
wavelength = good resolution

The downside of the better resolution achieved

with higher frequencies is lack of penetration of the
ultrasound beam.
 To summarise:
Correct depth =
reasonable high frequency
= reasonably short wave
length = reasonably good
resolution.

Too much depth = low

frequency = long
wavelength = poor
resolution

Too little depth = Wont see

structures of interest !
 Resolution is described as three important types

Axial

Lateral

Temporal
 Axial Resolution
Separate two structures at different depths.

Axial resolution is determined by the pulse length.

The pulse length is the distance traveled by one

echo (3 cycles in this case).

Distance between objects must be greater than pulse length

to be seen as separate.
 Lateral Resolution
Ability to separate two structures lying side by side i.e.,
perpendicular to the beam axis.

Lateral resolution is directly related to the

transducer beam width, which in turn is inversely
related to the ultrasound frequency.
 Lateral resolution is poor
when the 2 structures lying
side by side are located
within the same beam
width.

Because the returning

echoes overlap with each
other side by side, the 2
structures (1 and 2 in
figure) will appear as one
on the display.
 The beam width can be
further reduced by
adjusting the focal zone
(FZ).

Lateral resolution is the

best at the FZ, where
the beam is narrowest.
 Temporal Resolution

Ability to separate two separate events in time, and correctly

display them as separate.

Directly related to Frame Rate (FR)

FR is the speed with which an imaging device produces unique
consecutive images

The eye generally can only see 25 FPS.

A higher frame rate offers the possibility of replay

at lower rate, i.e., 50 FPS played at 25 FPS, which
will in fact double the effective resolution of the
eye.
 FR is limited by sweep speed.

Sweep speed is limited by image depth.

Image depth should be just below target.

 Low attenuation High attenuation
(high penetration) (low penetration)

A proper transducer should be selected for a better

resolution.
 Transducer selection
Modern transducers are broad bandwidth
transducers that are designed to generate more
than one frequency.

With broad bandwidth transducers, the operator can

select the examination frequency to match the target
requirement.
 For superficial structures
(e.g. nerves in the
interscalene,
supraclavicular and
axillary regions), it is ideal
to use high frequency
transducers greater than
or equal to 7 MHz.
 For visualization of
deeper structures (e.g. in
the infraclavicular and
popliteal regions), it may
be necessary to use a
lower frequency
transducer, less than or
equal to 7 MHz.
 Curved transducers are
best suited for scanning
whenever a wide field of
view is required.

Curved transducers
often generate lower
frequency waves than
linear transducers thus
provide images of lower
resolution.
 Gain

Attenuation can be dealt with by gain.

Increasing gain amplifies the reflected signal in

post processing and not the transmitted signal.

Gain can be done at acquisition, or in post

processing.
 An increase in the
overall gain will
increase brightness of
the entire image,
including the
background noise.
 Time gain compensation (TGC)
Selectively amplify
the weaker signals
returning from deeper
structures.

This is a pre
processing function,
and has to be set at
acquisition.
 Reject
Low amplitude signals
can be filtered away,
resulting in filtering out
cavity noise.

However there is risk of

loosing low amplitude
signals (e.g. from
valves.) by the reject
function.
 Compress
The grey scale can be
compressed,
resulting in a steeper
saturation curve.

This means that the

picture goes to full
saturation (pure white)
at a lower amplitude,
while the brightness of
low amplitude signals
are reduced.
 Doppler effect
The Doppler effect was discovered by Christian
Andreas Doppler (1803 1853).

Shows how the frequency of an emitted wave

changes with the velocity of the emitter or
observer.

When the wave is bounced back from a stationary

object such as a nerve, both the transmitted and
the returned waves have the same frequency.
 However, the wave that bounces off an object
moving TOWARDS the probe will have a higher
frequency than the frequency of the wave
transmitted from the probe.

This is because the moving object squashes the

waves as it moves towards the probe
 Similarly, the wave that bounces off an object
moving AWAY from the probe will have a lower
frequency than the frequency of the wave
transmitted from the probe.

Higher emitted frequency from the

transducer

Lesser return frequency

The object moving away stretches the wave. The

stretching reduces the number of oscillations per
one second.
 Blood vessels are full of rapidly moving red blood
cells.

When using an ultrasound machine with the ability

to look for the doppler effect, the machine
analyses the frequency of the returned waves.

Whenever the returned wave has a frequency

different to the frequency of the transmitted wave,
the machine adds colour to those areas showing
the doppler effect.
BA RT
Doppler methods used for cardiac evaluation :

A. Continuous wave doppler

B. Pulsed wave doppler

C. color flow doppler

 CONTINUOUS WAVE DOPPLER

Employs two dedicated

ultrasound crystals, one
for continuous
transmission and a
second for continuous
reception.

This permits
measurement of very
high frequency Doppler
shifts or velocities.
Limitations of this technique:
It receives a continuous signal along the entire
length of the US beam

Thus, there may be overlap in certain settings,

such as:

stenoses in series (eg, left ventricular

outflow tract gradient and aortic stenosis) or

flows that are in close

proximity/alignment (eg, AS and MR)
 PULSED DOPPLER
Permits sampling of blood
flow velocities from a
specific region.
In contrast to continuous
wave Doppler which records
signal along the entire
length of the ultrasound
beam.

Is always performed with

2D guidance to determine
the sample volume
position.
Particularly useful for assessing the relatively low
velocity flows associated with:

1) transmitral or transtricuspid blood flow,

2) pulmonary venous flow,

3) left atrial appendage flow, or

4) for confirming the location of eccentric jets of

aortic insufficiency or mitral regurgitation
From a four-chamber view, a pulse wave Doppler signal is
placed in the superior portion of the left atrium at the entry
site of the right upper pulmonary vein
Note that the outline of pulmonary flow signal is seen
S: systolic wave; D: diastolic wave.
 Colour Doppler
With CF imaging,
velocities are displayed
using a color scale:
with flow toward
the transducer
displayed in
orange/red
flow away from the
transducer
displayed as blue
Apical four chamber view with color flow Doppler
during diastole
This color signal is used to position a pulsed wave
Doppler sample volume so that quantitatable signals
of flow can be obtained from the pulmonary veins
and from the mitral leaflet tips
 Image artifacts

Display distortions or errors that may adversely

affect image interpretation or acquisition.

Acoustic enhancement artifact

Acoustic shadow artifact

Reverberation artifact

Air artifact
 Acoustic enhancement artifact
Result of beam penetration through an area of low
attenuation coefficient to an area of higher
attenuation coefficient.

An acoustic enhancement artifact (hyperechoic

region, arrow) deep to a fluid filled structure (A =
artery).
 Acoustic shadow artifact
Result of beam attenuation when the beam
encounters tissue with a high attenuation
coefficient.

An acoustic shadow artifact (hypoechoic

region = bone shadow) deep to a hyperechoic
bone outline (arrows).
 Reverberation artifact
Reverberations is defined as the phenomenon that
a sound pulse bounce back between different
structures before being reflected back to the
observer.
 Tissue reverberation artifacts are generated by
strong specular reflectors (yellow arrowheads).

Air artifact in the lung results in "comet tail"

acoustic signals (arrows) going from the
hyperechoic pleural line into the lung parenchyma.
 Reverberation artifacts (white arrows) can be
seen during needle (yellow arrows)
advancement in the infraclavicular region using a
curved transducer.
Air artifact

The air artifact (arrows) at the transducer skin

interface is due to a lack of conductive gel and
poor transducer to skin contact. This results in a
large dropout artifact.
3 important factors for ultrasound
scanning
3.operator

1.Ultrasoun
d machine
2.probe
 Holding the probe

The probe should be

held low down with the
ulnar border of the hand
acting as a tripod so that
the probe can be held
still during procedure.
Body Ergonomics
Body Ergonomics
 Proper scanning technique PART to
capture good image
P - Pressure

A - Alignment

R - Rotation

T - Tilting
 Pressure

Correct pressure
application can
considerably improve the
image quality.

It affects the echogenicity

of the tissue and shortens
the distance to the
structure of interest.
 Alignment (Sliding)
Refers to the task of
sliding the transducer
longitudinally to follow
the course of the target
e.g., a nerve. or a
needle..

The main goal of this

maneuver is to find the
structure of interest and
position it optimally on
the screen for needle
advancement.
Tracing the Course of the Ulnar Nerve by Sliding
the Transducer Longitudinally
 Rotation
Rotating the transducer (clockwise / counter-clockwise).

Goals achieved are:

a true axial view of the target can be attained with its long axis
parallel to the surface but not perpendicular to the current US
plane.

the target can be aligned into a more favorable trajectory for a

safe needle pass (away from vessels or pleura, for example).
 Tilting
Angling the probe.

Can improve image

quality by aligning the
ultrasound beam
perpendicular to the target
(nerve or needle).
e.g. the shape of the target
on the screen will be true
(round instead of oval, for
example).
and the distance travelled
will be shorter.
 Anisotropy

Defined as a tissue property that is responsible

for changes in the US reflection dramatically,
even with mild changes in the angle of
incidence.

It creates the phenomenon known as now-you-

see-me-now-you-dont.
 The needle shaft is poorly visualized in
figure A but becomes easily visualized
when the beam angle is steered at a 13
degree angle in figure B.

The needle shaft is poorly visualized in figure A but

becomes easily visualized when the beam angle is
steered at a 13 degree angle in figure B.
 NEEDLE ADVANCEMENT
TERMINOLOGY AND TECHNIQUES

In-plane needle placement

occurs when the needle can be seen on the
US monitor in the long-axis view (long axis of
the needle is situated within the US scanning
plane).

Out-of-plane needle placement

occurs when the long axis of the needle is
directed across the scanning plane so the
needle can be seen in the short-axis view
In in-plane technique (left), needle is aligned in the plane of thin
ultrasound beam allowing the visualization of the entire shaft and
the tip.
In out-of plane technique (right), the ultrasound beam transects the
needle, and the needle tip or the shaft is observed as a bright spot
in the image.
 In-plane needling is commonly used for single
injections,
while out-of-plane is used for catheter
placement.

For visualization of the tip of the needle,

it is common to use tissue movement,

or injections of small volumes of dextrose (if

nerve stimulation is planned),

or normal saline as an indicator (hydrolocation).

 How safe is USG
The primary concerns of the use of ultrasound
technology are with respect to
thermal effects of the insonated tissue, and
cavitation of tissue .

The ultrasound wave affects the tissue through

which it travels by mechanical vibration and heating
of the tissue.

Mechanical vibration can result in cavitation or the

formation of gas bubbles which typically occurs at
the interface of tissues and gas.
 ALARA principle (as low as reasonably
achievable):
lowest amount of energy possible for obtaining the
necessary diagnostic information.

The acoustic output of modern ultrasound

machines can be measured via two measurements
displayed on the monitor:
TI and
MI
 Thermal Index (TI)

TI is an estimate of the degree of temperature

elevation.

A TI of 1 indicates a power causing a temperature

increase of 1C.

If TI is above 1.0, there is a chance for

temperature elevation of the insonated tissue.
Careful in febrile patients.
 The World Federation for Ultrasound in Medicine
and Biology
concluded a diagnostic exposure that produces a
maximum temperature rise of
no more than 1.5C
above normal physiological levels (37C)
may be used without reservation on thermal
grounds.
 Mechanical Index (MI)
MI is an estimate of the compressive and
decompressive mechanical effects of ultrasound
pulses, which can potentially result in cavitation.

The FDA imposes an upper limit of 1.9 for the MI.

American Institute of Ultrasound in Medicine
"No independently confirmed adverse effects
caused by exposure from present diagnostic
ultrasound instruments have been reported in
human patients in the absence of contrast agents.
Biological effects (such as localized pulmonary
bleeding) have been reported in mammalian
systems at diagnostically relevant exposures, but
the clinical significance of such effects is not yet
known.
Ultrasound should be used by qualified health
professionals to provide medical benefit to the
patient"
 REFERENCES
Basic ultrasound, echocardiography and
Doppler for clinicians by Asbjrn Stylen, dr.
med. http://www.ntnu.no/indexe.php
how equipment works.com by Dr. Prasanna
Tilakaratna http://www.howequipmentworks.com/
Ultrasound for Regional Anesthesia and Pain
management, Toronto Western Hospital,
http://www.usra.ca/index.php
Uptodate 21.2
Various internet articles, images and videos.