The Ultrasound Machine

A basic ultrasound machine has the following parts:

Transducer probe - probe that sends and receives the sound

waves

Central processing unit (CPU) - computer that does all of the calculations and contains the electrical power supplies for itself and the transducer probe

Transducer pulse controls - changes the amplitude, frequency and duration of the pulses emitted from the transducer probe
Display - displays the image from the ultrasound data processed the CPU Keyboard/cursor - inputs data and takes measurements from the display Disk storage device (hard, floppy, CD) - stores the acquired images Printer - prints the image from the displayed data by

Ultrasound parts

Ultrasound
Ultrasound is simply sound waves, like audible sound. Although some physical properties is dependent on the frequency, the basic principles are the same. Sound consists of waves of compression and decompression of the transmitting medium (e.g. air or water), traveling at a fixed velocity. Sound is an example of a longitudinal wave oscillating back and forth in the direction the sound wave travels, thus consisting of successive zones of compression and rarefaction. Transverse waves are oscillations in the transverse direction of the propagation. (For instance surface waves on water or electromagnetic radiation.)

Fig. 1. Schematic illustration of a longitudinal compression wave (top) and transverse wave (bottom). The bottom figure can also represent the pressure amplitude of the sound wave.

The audible sound frequencies are below 15 000 to 20 000 Hz, while diagnostic ultrasound is in the range of 1 - 12 MHz. Audible sound travels around corners, we can hear sounds around a corner (sound diffraction). With higher frequencies Shorter wavelengths) the sound tend to move more in straight lines like electromagnetic beams, and will be reflected like light beams. They will be reflected by much smaller objects (also because of shorter wavelengths), and does not propagate easily in gaseous media. The wavelength velocity c: is inversely related to the frequency f by the sound

Meaning that the velocity equals the wavelength times the number of oscillations per second, and thus:

The sound velocity i a given material is constant (at a given temperature), but varies in different materials
Material Air Water Fat Average soft tissue Velocity ( m/s) 330 1497 1440 1540

Blood Muscle Bone Metal

1570 1500 - 1630 2700 - 4100 3000 - 6000

Ultrasound is generated by piezoelectric crystals that vibrates when compressed and decompressed by an alternating current applied across the crystal, the same crystals can act as receivers of reflected ultrasound, the vibrations induced by the ultrasound pulse

What are the ultrasound data?

The ultrasound data can be sampled at different levels of complexity as shown below: A.

Basically, a reflected ultrasound pulse is a waveform. However, storing the full waveform, called RF data, is demanding in terms of storage, as each point on the curve would have to be represented in some way or other. However, if the full RF data are stored, the amplitude and frequency data could both be calculated in post processing.

B.

The pulse has a certain amplitude. Just storing the amplitude is much les demanding (corresponding more or less to one number per pulse). This is the only data that are used in grey scale imaging, where the amplitude is displayed as brightness of the point corresponding to the scatterer as in Bmode and M-mode.

C.

However, the reflected ultrasound pulse has a frequency (or a spectrum of frequencies), and this can be represented as a numerical value per image pixel as well, as described in Doppler imaging. Still, the amount of data is far less than the RF data.

Imaging by ultrasound
Basically, all ultrasound imaging is performed by emitting a pulse, which is partly reflected from a boundary between two tissue structures, and partly transmitted (fig. 2). The reflection depends on the difference in impedance of the two tissues. Basic imaging by ultrasound does only use the amplitude information in the reflected signal. One pulse is emitted, the reflected signal, however, is sampled more or less continuously (actually multiple times). As the velocity of sound in tissue is fairly constant, the time between the emission of a pulse and the reception of a reflected signal is dependent on the distance; i.e. the depth of the reflecting structure. The reflected pulses are thus sampled at multiple time intervals (multiple range gating), corresponding to multiple depths, and displayed in the image as depth. Different structures will reflect different amount of the emitted energy, and thus the reflected signal from different depths will have different amplitudes as shown below. The time before a new pulse is sent out, is dependent of the maximum desired depth that is desired to image.

Fig. 2. Schematic illustration of the reflection of an ultrasound pulse emitted from the probe P, being reflected at a, b and c. Part of the pulse energy is transmitted from the scatterer a, the rest is transmitted, part from b and the rest from c. When the pulse returns to P, the reflected pulse gives information of two measurements: The amplitude of the reflected signal, and the time it takes returning, which is dependent on the distance from the probe(twice the time the sound uses to travel the distance between the transmitter and the reflector, as the sound travels back and forth). The amount of energy being reflected from each point is given in the diagram as the amplitude. When this is measured, the scatterer is displayed with amplitude and position. Thus, the incoming pulse a a is the full amplitude of P. At b, the incoming (incident) pulse is the pulse transmitted through a. At c, the incident pulse is the transmitted pulse from b. (In bot cases minus further attenuation in the interval.)

 The time lag, , between emitting and receiving a pulse is the time it takes for sound to travel the distance to the scatterer and back, i.e. twice the range, r, to the scatterer at the speed of sound, c, in the tissue. Thus:

The pulse is thus emitted, and the system is set to await the reflected signals, calculating the depth of the scatterer on the basis of the time from emission to reception of the signal. The total time for awaiting the reflected ultrasound is determined by the preset depth desired in the image.

The received energy at a certain time, i.e. from a certain depth, can be displayed as energy amplitude, A-mode. The amplitude can also be displayed as the brightness of the certain point representing the scatterer, in a B.mode plot. And if some of the scatterers are moving, the motion curve can be traced by letting the B-mode image sweep across a screen or paper as illustrated in fig. 3. This is called the M-mode (Motion).

Fig. 3a. The ultrasound image is built up as a line of echoes based on the time lag and amplitude of the reflected signals

Fig. 3b. The reflected signals can be displayed in three different modes. A-mode (Amplitude) shows the depth and the reflected energy from each scatterer. B-mode (Brightness) shows the energy or signal amplitude as the brightness (in this case the higher energy is shown darker, against a light background) of the point. The bottom scatterer is moving. If the depth is shown in a time plot, the motion is seen as a curve, (and horizontal lines for the non moving scatterers) in a Mmode plot (Motion).

The ratio of the amplitude (energy) of the reflected pulse and the incident is called the reflection coefficient. The ratio of the amplitude of the incident pulse and the transmitted pulse is called the transmission coefficient. Both are dependent on the differences in acoustic impedance of the two materials. The acoustic impedance of a medium is the speed of sound in the material the density: Z=c
Thus, if the velocities of sound in two materials are very different, the reflection will be close to total, and no energy will pass into the deepes material. This occurs in bondary zones between f.i. soft tissue and bone, and soft tissue and air. This means that the deepest material can be considered to be in a shadow. The reflecting structures does not only reflect directly back to the transmitter, but scatters the ultrasound in more directions. Thus, the reflecting structures are usually termed scatterers

It's important to realise that the actual amount of energy that is reflected back to the probe; i.e. the amplitude of the reflected signal, is not only dependent on the reflection coefficient. The direction of the reflected signal is also important. Thus: - An irregular scatterer will reflect only a portion back to the probe. - A more regular scatterer will reflect more if the reflecting surfaces are perpendicular to the ultrasound beam.

Effect of size and direction of the reflecting surface. The two images on the left shows a perfect reflecting surface. Most of the energy (but not all, as the wave front is not flat), will reflect back to the transducer resulting in a high amplitude echo, when the surface is

perpendicular to the ultrasound beam.

On the other hand, if this surface is tilted 45, almost all energy will be reflected away from the surface, resulting in a very low amplitude return echo to the probe.

The next two images shows a scattered with a more curved surface, resulting in
more energy being spread out in different directions, this will give a lower amplitude signal back to the probe, but may reflect more energy back towards the probe if it is tilted, as for instance when the heart contracts, walls changing direction. Finally, to the left, a totally irregular surface will reflect the sound in all directions, butt very little net reflections toward the probe

The effect of the direction of the reflecting surface in a long axix image of the left ventricle. The echo resulting from the septum-blood interface (arrows) is far stronger in the regions where the surfaces are perpendicular to the ultrasound beams (blue arrows), compared to the region between where the surface is slanted compared to the ultrasound beams.

Cyclic variations in the amplitude in reflected ultrasound (integrated backscatter) with heart cycle. This reflect the variations in reflexivity, but not myocardial density, as the myocardium is incompressible. Thus, most of the amplitude variations must be due to changes in fiber directions

The term: Reflection is used about the return signal, while scattering is used about dispersion of the reflected signal, but as the figure above shows, it's the same process.

Thus, the apparent density of the tissue on the ultrasound image is as dependent on the wall and fiber direction. A part of the heart where the fibers run mainly in a direction across the ultrasound beams, will look much denser. Variations in amplitude (brightness of the reflected signal) do not necessarily mean differences in density, but may also mean variations in reflectivity due to variation in the direction of the reflections. Thus, integrated backscatter can be used for studying of cyclicity, but it is not useful for tissue characterisation.

Absorption
Some of the energy of the ultrasound is absorbed by the tissues, and converted to heat. This indicates that it may have biological effects, if the absorbed energy is high enough.
Absorption is important for two reasons: The heating of the tissue is the safety limitation on ultrasound equipment. The absorbed energy has to remain within limits that does not heat the tissue to dangerous temperatures. The absorption can be calculated, and in commercial equipment today, the limitation is imposed in the limitation of the total energy that can be transmitted (which is expressed by the mechanical index). The attenuation, which is mainly due to absorption, is the limiting factor for the depth penetration of the beam, i.e. the depth to which the beam can be transmitted.

The absorption is dependent on many factors :

1. The density of the tissue. The higher the density, the more absorption. Thus the attenuation is fluid < fat < muscle < fibrous tissue < calcifications and bone. 2. The frequency of the ultrasound beam. The higher the frequency, the more absorption. In human tissue, a general approximation is that the attenuation is 1 dB/cm MHz (however, that is for one way, in imaging the distance is 2* the depth). Thus, the desired depth to be imaged, sets the limit for how high frequency that can be used. As can be seen, penetration might be increased by increasing the transmitted energy, but this would increase the total absorbed energy as well, which has to stay below the safety limits.

Ultrasound Power / mechanical index

The ultrasound power is the amplitude of the transmitted signal, at the probe. I.e. The total energy that is transmitted into the patient. This is measured in deciBels. The mechanical index, is the amount of energy that is absorbed by the patient. This, however is not only dependent on the power, but also on the focusing of the beam, and is highest where the beam is focused, but it also decreases with depth. Thus, the mechanical index is a measure of the possible biological effects of the ultrasound, and is usually calculated and given as a maximal theoretical entity, by the equipment. Usually, it may vary between 1.5 (in B-mode) and 0.1 (in contrast applications).

Attenuation
It follows that the ultrasound waves are attenuated as some of the energy is reflected or scattered. Thus, in passing through tissue, the energy is attenuated due to the reflection that is necessary to build an image. Attenuation will have effect on the image in other ways, as shown blow.

Attenuation. Imaging of a homogeneous tissue, f.i. liver will change the apparent density behind structures with different attenuation. Behind a structure with high reflexivity (e.g. a calcification), there will be high attenuation, (white; left). Hence, the sector behind receives less energy, and appears less dense (darker), the area behind may even be a full shadow. Behind a strcture with low reflexivity (e.g. a fluid) there is little attenuation (black; right), the tissue receives more energy and appears denser (brighter - "colouring") than the surrounding tissue.

Liver with a gallbladder in front, containing gallstones. The gallstones are dense, with a shadow behind. The rest of the gallbladdeer is fluid filled, thus the sector behind the fluid appears denser than the neighbouring tissue due to "colouring"

This is about 10% of the total energy loss. In addition, the ultrasound waves are diffracted, resulting in further diffusion of the waves out into the surrounding tissue and loss in the energy available for reflection (imaging). However, the most important factor is the the ultrasound energy is attenuated due to absorption in the tissue, this absorption process generates heating of the tissue. It follows that as attenuation is energy loss, this means that the attenuation increases with increasing depth. ( And the reflections are further attenuated in passing back toward the probe) The attenuation is the limiting factor for the depth penetration of the beam, i.e. the depth to which the beam can be transmitted, and still give useful signals back. Basically, the shorter the wavelength, the higher the attenuation (and thus the shorter the depth penetration). The effective range can be said to be about 200 300 x . For practical medical purposes, the penetration for good imaging is about 10 - 20 cm at 3.5 MHz (adult cardiac), 5 - 10 cm at about 5 MHZ (pediatric cardiac), 2-5 cm at 7.5 MHz, 1-4 cm at 10 MHZ, the last two frequencies being in the vascular domain. However, one method to bypass some of the attenuation problem is by harmonic imaging. Thus the beam is transmitted at a certain frequency, and the received signal is analyzed at twice that frequency (Fourier analysis). This increases the signal to noise ratio of the reflected signal, especially at the deepest parts of the image, without a similar loss of resolution

Gain
Attenuation can be dealt with by gain, increasing gain amplifies the reflected signal in post processing. However, increased gain increases signal and noise in the same manner. Gain can be done at acquisition, or in post processing.

Uncompensated image, showing decreasing signal intensity (and, hence, visibility) with depth, due to attenuation.

Increasing over all gain, will increase the amplitude of the signal, and the structures at the bottom of the sector becomes more visible. But the gain in the top of the sector are also increased, including the cavity noise, thus decreasing contast in this part of the image

Time gain compensation (TGC)

All commercial equipment today has a time gain compensation (TGC). This increases the gain of the reflected signals with increasing time from the transmitted pulse; equivalent to increasing the gain with increasing depth. However, this is not a perfect solution, as the signal-to-noise ratio may decrease, if the noise does not decrease similarly with depth. However, it will give a better balance in the picture, and compensate for much of the attenuation effects. This is a pre processing function, and has to be set at acquisition TGC controls. Basically, each slider controls gain selectively at a certain depth:

In older models, the TGC should be set manually to achieve a balanced image:

Present models, however, have automatic TGC. Thus the default control setting should be neutral to achieve a balanced picture:

Using manual setting by old habit will result in a double compensation, with too much gain in the bottom, too little in the top:

Compress and reject:

Low amplitude signals can be filtered away, resulting in filtering out cavity noise, however at the price of risking to loose low amplitude signals (e.g. from valves.) by the reject function. Finally, 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. It is important to realise that all these are post-processing functions that manipulates the image on the screen, without improving the signal quality itself, or the fundamental signal to noise ratio.

Image with default gain, reject and compress settings

Principle of gain, reject and compress. All curves display brightness of the display in relation to the amplitude of the rejected signal. An ordinary gain curve is shown in black, using a linear brightness scale, displays the full range of amplitudes. Increasing gain (red curve), will increase all signals, including the weakest, as in the noise. The disadvantage , in addition to increasing noise, is that the strongest signals will be saturated, so details may disappear. Compress is shown as the blue curve. This results in a steeper brightness curve, resulting in less brightness of the weakest echoes, and more brightness of the strongest. Thus, weak echoes may disappear together with background noise, while strong echoes will be saturated, resulting in loss of detail. Finally reject is shown by the light grey zone, simply displaying all signals below a certain amplitude as black. (The black brightness curve drops abruptly to zero at the reject limit (dark grey line). A combination of high gain and reject will give an effect fairly similar to the compress function.

Same image with high gain (top) showing increased density of the endocardium , but loss of detail due to brightness saturation and a corresponding increase in cavity noise and low gain (bottom), showing reduction in cavity noise, but loss of detail (see endocardium in lateral wall).

Same image with increased reject (top) showing reduction in cavity noise, but also with slight loss of detail (endocardium in lateral wall) and compress function (bottom) with less detail in the myocardium due to increased brightness.

All commercial equipment today has a time gain compensation (TGC), increasing the gain of the reflected signals with increasing time from the transmitted pulse. This is equivalent to increasing the gain with increasing depth. However, this is not a perfect solution, as the noise is constant with depth, while the reflected signals become weaker, and with TGC, the noise will be gained as well as the signal, and the signal-to-noise ratio will decrease, thus the resulting signal will end up as a grey blur at a certain depth. This effect can be seen below. Before harmonic imaging, the TGC was adjustable, relying on the operator to optimise the visibility. AS the greater part of cavity noise is removed by the harmonic imaging, most modern equipment has automated TGC, but retains the possibility of manual adjustment

M-mode
The M-mode was the first ultrasound modality to record display moving echoes from the heart (118), and thus the motion could be interpreted in terms of myocardial and valvular function. The M-modes were originally recorded without access to 2-dimensional images

Fig. 4. Typical M-mode images. a from left ventricle, b from the mitral valve and c from the aortic valve as indicated on the 2D long axis image above. Here the amplitude is displayed in white on dark background

Depth resolution Bandwidth:

The depth resolution of the ultrasound beam, is the resolution along the beam. This is dependent on the length of the transmitted ultrasound pulse. In a blood / tissue interface, the dividing line can be seen as a bright line, which does not reflect a tissue stricture (typically NOT the intima, being far too thin to be seen with ultrasound at the present frequences), but the pulse length. This is the reason for the ASE convention, where depths are measured from leading - to - leading edge of the echoes, as this will neutralise the pulse length form measurements.

Ideally, the pulse length in imaging (B- and M-mode) should be as short as possible, but this is dependent on the physical properties of the probe. Most probes will ring in the resonance frequency for a few oscillations, and thus produce a pulse with a length of several oscillations. By Fourier analysis, the frequency content of the pulse will be less dispersed, the longer the pulse is. Thus, the pulse length is inversely proportional with the spread of the frequency, i.e. the bandwidth of the pulse, as shown below. This will have consequences for Doppler imaging, where frequencies, and not amplitudes are analysed.

Two different pulses with the same frequency, but different duration (pulse length), i.e. Number of oscillations. The shortest pulse has a wider dispersion of frequencies, i.e. a greater bandwidth. After Angelsen .

Higher frequencies will result in shorter pulses for the same number of oscillations, i.e. reduce pulse length without increasing bandwidth to the same degree. Thus, for imaging, the ideal pulse would be highest possible frequency (depending on the required depth penetration) and the shortest possible pulse length. However, as noise is unevenly distributed in different frequency domains, harmonic imaging, which analyses at half the frequency, will result in less noise. Harmonic imaging thus doubles the pulse length for a given frequency, and results in thicker echoes.

Halving the frequency results in half the number of oscillations per time unit, or longer time (= pulse length) for the same number of oscillations. Thus halving the frequency, as in second harmonic analysis, will result in longer pulse length. However, the bandwidth is far less affected.
NOTE: The most important point is that the echo from an interface reflects the pulse length, and is NOT a picture of the endothelium.

Second harmonic (1.7/3.5 MHz) left and fundmental (3.5 MHz) right images of LV septum, showing how the echo from the blood/septum interface (arrows) is thicker in harmonic imaging, due to the reduction in frequency. Observe, however, how cavity noise is much reduced in harmonic imaging, resulting in a far more favorable signal-to-noise ratio.

The thickness of the surface echoes is dependent n the pulse length, and thus also on the frequency. This picture of the septum illustrates how the leading-to-leading ASE convention shown in red , eliminates the pulse length in measurement (as the echo blooms in both directions), while the Penn convention will result in increasing overestimation of the thickness by increasing pulse length as it incorporates the interface on both sides

2-dimensional imaging :
A 2-dimensional image is built up by firing a beam vertically, waiting for the return echoes, maintaining the information and then firing a new line from a neighboring transducer along a tambourine line in a sequence of B-mode lines. In a linear array of ultrasound crystals, the electronic phased array shoot parallel beams in sequence, creating a field that is as wide as the probe length (footprint). A curvilinear array has a curved surface, creating a field in the depth that is wider than the footprint of the probe, making it possible to create a smaller footprint for easier access through small windows. This will result in a wider field in depth, but at the cost of reduced lateral resolution as the scan lines diverge.