Basic ultrasound

Demsew Befkad, MD.

( Assistant professor of
clinical radiology)
Outline

 What is ultrasound imaging

 Properties of sound
 How does it works
 Instrumentation
 Basic terminologies
 Common uses
 Safety
 Cases
Introduction

 Ultrasound is very high frequency (high

pitch) sound.
 Human ears can detect sound with
frequencies lying between 20 Hz and 20
kHz.
 Ultrasound > 20 khz , infrasound < 20 hz
What is ultrasound imaging

 Exposing partis of body to high frequney sound

wave to produce pictures inside the body
 Do not use ionizing radiation
 Real time imaging
 Ultrasound as a diagnostic tool:

Positives
 Readily available
 Available at the bedside/portable
 Non-ionising
 Dynamic & real-time test with instant results
 Very few contraindications

Negatives
 Specialised and requires training – operator dependence
 Prone to artefact – particularly gas and calcification
 Not useful for assessing tissues with high acoustic
impedance – bone; air etc.
 Depth-limited
Basic characteristics of sound
 Sound is mechanical
wave travel through
media longitudinally
with compression and
rarefaction
 Frequency
 Period
 Amplitude
 Power
 Intensity
 Wavelength
 Propagation speed
Interaction with Tissue

 Attenuation
 is the gradual weakening of the
ultrasound beam as it passes
through tissue. Attenuation can
be caused by reflection,
scattering, or absorption of the
sound waves
 Reflection
 Takes place when ultrasound
waves are bounced back to the
transducer for image generation.
 The portion of the ultrasound
beam that is reflected is
determined by the difference in
acoustic impedance between
adjacent structures
 Scattering
 refers to the redirection of ultrasound
waves as they interact with small,
rough, or uneven structures.
 Absorption
 occurs when the energy of the
ultrasound beam is converted to
heat. This occurs at the molecular
level as the beam passes through
the tissues
 Refraction
 curs when the ultrasound beam hits
a structure at an oblique angle. The
change in tissue density produces a
change in velocity, and this change
in velocity causes the beam to bend,
or refract
Formation of ultrasound beam:
• Piezoelectric crystals
deform and vibrate
when voltage is applied
across them

• This generates sound

wave which can pass
into tissue

• Can be continuous or
pulsed – pulsing of wave
achieved through
introducing delay(s) to
the voltage applied
Formation of ultrasound beam:
• Sound consists of travelling
pressure waves
• Because of the longitudinal
nature of wave – there are
periods of compression and
rarefaction within wave
• As sound passes through tissue
– the irregularities within tissue
deform the wave
• Reflected wave detected by US
probe vibrates the crystals in a
specific way that can be ‘read’
by the US machine and
displayed on an image.
 Generation of image
 Sound waves pass through
layers of tissue, encounter an
interface b/n tissues of different
densities & reflected back to
the transducer & converted
back to electrical energy
&displayed on the screen.

 The picture displayed on the

screen is produced by sound
waves reflected back from the
imaged structure.
Generation of image:
Ultrasound waves do not
pass through air well;
therefore, coupling gel is
necessary

The gel also permits the

ultrasound probe to gently
slide over the abdomen or
along the vagina
Image Display

 A-mode (amplitude mode) and bistable display to

high-resolution, real-time, grayscale imaging
 M-mode (motion-mode) ultrasound, displays echo
amplitude and shows the position of
 The mainstay of imaging with ultrasound is
provided by real-time, gray-scale, B-mode display,
in which variations in display intensity or
brightness are used to indicate reflected signals
Different type of Ultrasound display
mode
 A-mode
 B-Mode
 Dense tissues such as bone produce high
velocity reflected waves and appear white
on screen and
 Fluids generate few reflected waves &
appear black on screen.
M-mode
•Doppler
•Color flow
•Spectral Doppler
INSTRUMENTATION

 all consist of the following basic components to

perform key functions
 Transmitter or pulser to energize the transducer
 Ultrasound transducer
 Receiver and processor to detect and amplify the
backscattered energy and manipulate the reflected
signals for display
 Display that presents the ultrasound image or data in a
form suitable for analysis and interpretation
 Method to record or store the ultrasound image
 Transducer
 (1) converting the electric energy provided by the
transmitter to the acoustic pulses directed into the
patient and
 (2) serving as the receiver of reflected echoes,
converting weak pressure changes into electric
signals for processing.
 Types of probes/transducers
Linear array transducer
 Emits sound waves parallel
to each other and produces
a rectangular image
 Used primarily with high
frequencies (5-7.5 MHz)
 Optimal for evaluating
structures in the near field
Sector Transducer
 Produces a fan like
image.
 Narrow near the
transducer & increases
in width with deeper
penetration

 Are better at evaluating

deeper structures
Curved/convex
array
 Gives a wide near and
far zone is handled
easier than sector
 Are a combination of
the linear array and
sector transducers.

 They allow a larger

near field with a
retained large far
field.
Terminologies

 Anechoic (Black)
 on ultrasound means no
internal echoes are emitted
and there is a completely
black appearance. This is
most commonly seen with
fluid-filled structures since
ultrasound waves pass
through fluid without
reflecting any echoes back
to the ultrasound machine.
Hyperechoic (Bright/White)

 means that a specific

structure gives off MORE
echoes relative to it’s
surrounding structures
resulting in a
brighter/whiter
appearance.
 Hypoechoic (Darker/Grey)

 means that a specific

structure gives off
fewer echoes relative
to it’s surrounding
structures resulting in
a darker or more grey
appearance.
Isochoic (Similar)

 means that a specific

structure gives off similar
echoes relative to another
structure on the
ultrasound screen.
 Posterior shadowing
 is caused by partial or
total reflection or
absorption of the sound
energy A much weaker
signal returns from behind
a strong reflector (air) or
sound-absorbing structure
(gallstone, kidney stone,
bone)
 posterior enhancement,
 the area behind an echo-weak
or echo-free structure appears
brighter (more echogenic)
than its surrounding
structures , signals must pass
through more attenuating
structures and return with
comparatively weaker echoes
 A common place for this to
occur is posterior to the
anechoic bladder
 Reverberation
 occurs when sound encounters
two highly reflective layers.
 The sound is bounced back
and forth between the two
layers before returning to the
transducer
 The probe detects prolonged
travel time and correlates with
a further distance, displaying
additional ‘reverberated’
images in a deeper tissue
layer
Common uses

 Trans fontanel ultrasound

 Neck ultrasound
 Chest ultrasound
 Musculoskeletal ultrasound
 Abdominal / pelvic ultrasound
 Obsterics ultrasound
 Ultrasound guided biopsy/ FNA or innervations
Transfontanelle ultrasound
 Commonly used for infants
(age <1 yr
 Indications –
 routine head ultrasound for
all premature neonates
 suspicion of brain anomalies
on antenatal ultrasound
 any sick neonate in whom
brain pathology is implicated
 a neonate that had not been
screened prenatally
 Technique
Neck ultrasound

 Thyroid pathologies
 Neck mass
 Lymphadenopathis
 Salivary gland pathologies
Chest ultrasound
 Pleural fluid collection
 Pleural mass
 Peripheral
consolidation
 Pneumothorax
 Cardiac( echocardiogra
phy)
 Localized pain (rib
fractures)
 Chest wall masses
Abdominal Ultrasound

 indications
 abdominal pain
 altered liver function tests
 jaundice
 renal symptoms (consider
renal US)
 important pathology
 gallstone disease
 acute cholecystitis
 renal tract calculi
 abdominal aortic aneurysm
 US pelvis
 exclusively for female
patients
 performed with a full bladder
 uterus, ovaries and adnexa
 can be performed TA
(transabdominal) or TV
(transvaginal)
 Obstetrics ultrasound
 First-Trimester Ultrasound Examination
a. Confirmation of the presence of an intrauterine
pregnancy;
b. Evaluation of a suspected ectopic pregnancy;
c. Defining the cause of vaginal bleeding;
d. Evaluation of pelvic pain;
e. Estimation of gestational (menstrual) age;
f. Diagnosis or evaluation of multiple gestations;
g. Confirmation of cardiac activity;
h. Imaging as an adjunct to chorionic villus sampling
i. Assessing for certain fetal anomalies, such as
anencephaly, in high-risk patients;
j. Evaluation of maternal pelvic masses and/or uterine
abnormalities;
k. Measuring the nuchal translucency (NT)
l. Evaluation of a suspected hydatidiform mole.
Second- and Third-Trimester Ultrasound Examination

a. Screening for fetal anomalies; m. Evaluation of a suspected hydatidiform mole;

b. Evaluation of fetal anatomy; n. Adjunct to cervical cerclage placement;
c. Estimation of gestational (menstrual) o. Suspected ectopic pregnancy;
age; p. Suspected fetal death;
d. Evaluation of fetal growth; q. Suspected uterine abnormalities;
e. Evaluation of vaginal bleeding; r. Evaluation of fetal well-being;
f. Evaluation of abdominal or pelvic pain; s. Suspected amniotic fluid abnormalities;
g. Evaluation of cervical insufficiency; t. Suspected placental abruption;
h. Determination of fetal presentation; u. Adjunct to external cephalic version;
i. Evaluation of suspected multiple v. Evaluation of PROM
gestation;
w. Evaluation of abnormal biochemical markers;
j. Adjunct to amniocentesis or other
x. Follow-up evaluation of a fetal anomaly;
procedure;
y. Follow-up evaluation of placental location
k. Evaluation of a significant discrepancy
between uterine size and clinical dates; z. History of previous congenital anomaly;
l. Evaluation of a pelvic mass;
BASIC PROCEDURE AND TECHNIQUES

 patient fasted for 4 hours

 maximises distension of the gallbladder
 not required post cholecystectomy
 patient scanned supine
 oblique and lateral positions may be used during the study

 Preprocedure issues — The sonographer should know

the reason for the ultrasound examination

 The patient's abdomen is exposed from the pubic

bone to the umbilicus or xiphoid
 The transabdominal
ultrasound probe is held in
the right hand with the
mark (ie, a groove or ridge
on one side of the
ultrasound transducer) on
the thumb side
 With this orientation, the
right side of the patient is
displayed on the left side of
the ultrasound imaging
screen
 The top of the image (the
small angled portion)
represents structures that
are closer to the
transabdominal ultrasound
transducer

 The bottom of the image

(the wide pie shaped
perimeter) represents
structures further away from
the transducer.
Abdominal probe movements
 Sliding
 By holding the probe longitudinally and sliding it from side
to side across the abdomen
 Rotating
 This term describes rotation of the probe about a fixed
point
 Angling
 This describes an alteration of the angle of the complete
probe surface relative to the woman’s skin surface
 Dipping
 This describes pushing one end of the transducer into the
abdomen
Abdominal probe movements
 Sliding
 By holding the probe longitudinally and sliding it from side
to side across the abdomen
 Rotating
 This term describes rotation of the probe about a fixed
point
 Angling
 This describes an alteration of the angle of the complete
probe surface relative to the woman’s skin surface
 Dipping
 This describes pushing one end of the transducer into the
woman’s abdomen
 SAFETY
 The World Health Organization (WHO)
systematically reviewed 61 publications reporting
data on the safety of B mode or Doppler ultrasound
in human pregnancy

 These data showed that ultrasonography during

pregnancy was not associated with adverse
maternal/fetal/neonatal outcome, impaired
physical or neurological development, increased
risk of childhood malignancy, impaired cognitive
ability, or mental disease
 Two measurement of
acoustic output displayed
on the screen:
 The thermal index(TI)is an
increase in tissue temp
caused by us absorption.

 The mechanical
index(MI)is the measure
of gas bubbles generated
from tissue damage.
 If TI&MI <1 damage is
minimal.
Cases

Case -1 : A 48-year-old
female complained of
digestive disorders and
dyspepsia. She related
occasional pain in the
right upper quadrant of
the abdomen.
DDX.
An ultrasound exam was
performed.
 Case-2 : A 12-year-old
female patient was admitted
to the hospital with a 1-day
history of epigastric and
right lower quadrant pain,
fever, and vomiting.
Physical examination
revealed tenderness in right
lower quadrant. Laboratory
studies yielded leukocytosis
with neutrophilia
 Case 3
 Case 4- presented with
chest pain and cough
 Cases-5 : A 51-year-
old man experienced
a gradual onset of
pain and swelling in
his right calf 5 days
before admission. The
patient has been
immobilized for 3
weeks because of an
ankle strain.
Computed Tomography Overview
 Current multidetector computed tomography (MDCT) images are
generated with x-rays passing through the body in a helical fashion
as the patient moves through a gantry containing a rotating x-ray
tube
 Detectors on the opposite site of the tube collect the x-rays that
have passed through the body.
 Mathematical algorithms are used to reconstruct axial (transverse
plane) images of the body from the data collected by the detectors.
 Images in the sagittal and coronal planes and three-dimensional
renderings can be reconstructed by computer from the serial slices
of axial data. The gray-scale image can be manipulated on the
monitor.
 It relies upon x-rays to facilitate image creation.
 The x-ray tube is situated in a ring assembly that is able to spin
around the horizontal table that the patient lies on.
 The x-ray tube generates x-rays only when programmed and
activated by a CT Technologist.
 The detectors for the x-rays that pass through the patient are located
in the ring structure and rotate in unison with the source of the x-rays.
 The whole assembly that holds the x-ray tube and x-ray detectors is
in the large doughnut shaped part of the unit called, the gantry.
 At the same time that the tube and detectors spin the horizontal table
top that the patient lies on moves slowly through the gantry ring.
 This rotating x-ray source, associated with the rotating detectors, and
the horizontally moving table top is called a helical CT scanner.
 region on a CT image is described as being more, or
less, dense than another region. The liver is more dense
than the renal cortex.
– 1000 = Air
– 600 = Lung
– 120 to – 90= Fat
0= Water
– 5 to 15= Bile
10 to 15= CSF
20 to 40 = Soft Tissue
20 to 30= White Matter
37 to 45=Grey Matter
40 = Old Blood
 The viewer of the CT can decide how to
adjust the level and window of the
displayed CT images to accentuate
tissues of a defined pixel density. The
level and window are at the discretion
of the viewing radiologist and can be
set to their preferences. There are a
variety of established level and window
settings, i.e. abdomen, bone, brain, etc.
These help to provide some level of
uniformity for comparison of multiple
CT examinations. Level and window
setting for six common tissues are as
follows:
Indications

 Computed tomography is a useful and accurate cross-sectional

imaging test ideally suited for investigating possible pathology
in body cavities where the organs of interest may not be
accessible to superficial imaging techniques (e.g. ultrasound).
These cavities include the skull, thorax, abdomen and pelvis.
 CT is a good examination in a variety of conditions including:
 acute head injury;
 suspected subarachnoid hemorrhage;
 ureteric calculus;
 acute cervical spine trauma where there is a higher than average
likelihood of fracture or dislocation;
 suspected acute appendicitis in a non-pregnant patient.
 MRI
 Magnetic resonance images (MRI) are created by utilizing a high strength
magnetic field and radio waves.
 All of the protons in the body are aligned in the cranial/caudal axis by the
magnetic field of the MR.
 When a radio wave is broadcast into the body this perturbs the protons.
When the radio wave ceases the protons snap back to align with the
magnetic field.
 The protons liberate energy when they snap back into alignment with the
magnetic field. This liberated energy is detected by sensor coils
surrounding specific regions of the patient’s anatomy i.e. knee coils, head
coils, etc.
 Through a process of complex, computer based, mathematical
calculations the emitted energy is converted into pixels for digital image
creation, display, and review.
 Bright Versus Dark
 Tissues that have a short T1 will be bright.
 Tissues with a long T2 will be bright.
 Bright translates into whiter or having increased signal intensity on MRI scans.
 Dark translates into blacker or having decreased signal intensity on MRI.
 A key point is that water will be dark on T1-weighted images and
bright on T2-weighted images.
 Water is T1-dark and T2-bright. ♦ A “bright” way to remember the fact
that water is T2-bright is that the number “2” is both in H2O (water)
and T2 weighted.
 Therefore, when looking at any MR image, first try to find something you know
is fluid (water), such as the cerebrospinal fluid in the ventricles and spinal canal
or urine in the bladder.
 If the fluid is dark, then you are probably looking at a T1-weighted image
 If the fluid is bright, then chances are you are looking at a T2-weighted image
 Image Appearance

 The appearance of different tissue on MR images is described as

displaying greater, or lesser, signal in comparison the other anatomy in
the region. The signal in question is the energy that the perturbed
protons liberated when they fall back into alignment with the magnetic
field. The signal intensity of the tissue in question changes based upon
the image acquisition parameters set by the MR Technologist, under
the direction of a supervising Radiologist.
 The parameters set result in the acquisition of a set of images called an
MR imaging sequence. On one sequence cerebrospinal fluid will appear
as black pixels (T1 sequence) while on another sequence it is white
pixels (T2 sequence). This difference in tissue appearance can be
exploited to determine if pathology is present
 T1 Sequence – Cerebrospinal fluid appear as black
 T2 Sequence – Cerebrospinal fluid appears as white
 Certain tissues and structures are typically bright on T1-
weighted images.
 Fat: subcutaneous and intraabdominal fat, fat within
yellow bone marrow, fat-containing tumors
 Hemorrhage: varies depending on the age of the
hemorrhage
 Proteinaceous fluid: in renal or hepatic cysts, cystic
neoplasms However, a simple cyst containing water will
be dark on T1-weighted images (and bright on T2-
weighted
 Melanin: for example, melanoma
 Gadolinium and other paramagnetic substances
(manganese, copper)
 Certain tissues and structures are typically bright
on T2-weighted images.
 Fat: subcutaneous and intraabdominal fat, fat within
yellow bone marrow, fat-containing tumors
 Water, edema inflammation, infection, cysts
 Hemorrhage: varies depending on the age of the
hemorrhage
 Notice that both fat and hemorrhage can be T1-
bright and T2-bright.
 Image Acquisition
 Magnetic Resonance Imaging (MRI or MR), has the physical appearance of
a Computed Tomography machine, i.e. it has a long tube with a tabletop
that transports the patient into the centre of the tube for imaging.
Patients lie on their back (supine) in the MR machine just like CT. The
body region of interest for MR is surrounded by a coil that creates the
radio waves and captures the radio waves used to create the images. .
 There are MR machines that do not have a tube or bore configuration
called open magnets. They are designed to image children, obese
patients and claustrophobic patients. These units are less frequently
deployed in clinical practice.
 MRI can acquire images in any plane of anatomic orientation, but these
must be acquired as separate imaging sequences with unique technical
parameters set for each sequence. Therefore, the more MR sequences
planned, the longer the examination will take. This is unlike CT where the
creation of images in alternative anatomic planes is performed by
software manipulation of the pixels after image acquisition.
Indications

 Brain – indications include

 stroke, temporal lobe epilepsy, infection, inflammation,
tumour, multiple sclerosis (MS), dementia, post-trauma,
metabolic disorders, congenital malformations, internal
auditory canal pathology, vascular pathology, pituitary
fossa pathology, nerve palsies and metabolic disorders.
 Spinal cord – indications include
 radiculopathy, myelopathy, MS, inflammation, infection,
tumour, congenital malformation, postoperative
investigation and post-trauma.
 Musculoskeletal (MSK) – indications include all MSK
system:
 joints for derangement, infection, inflammation, post-
trauma, tumour and vascular pathologies. Plain films are
still very useful.
 Abdomen and pelvis –
 investigates pathology of the various organs including
tumours, vascular pathologies, infection, inflammation,
congenital abnormalities and metabolic disorders.
 detection of local invasion of rectal, prostatic and
cervical carcinomas, and assessing the anatomy in peri-
anal fistulae.
 Cardiac –
 ischaemia, tumour, infiltrative diseases, congenital
malformation and cardiomyopathy
 Vascular studies – increasingly being carried out
without contrast medium (so with no risk of contrast
allergy or nephrogenic systemic fibrosis
 Pregnancy – indications for the placental position and
invasion, as well as reviewing foetal anomalies,
particularly cerebral.
 Safety
 MRI is for the most part a very safe imaging modality. Some
examinations may require intravenous contrast agents (Gadolinium
based) and patients with known hyper-sensitivity to these agents should
not have MR with contrast. Gadolinium based contrast agents may also
cause renal injury in some patients who have predisposing poor renal
function. One should consult with the imaging centre prior to booking a
patient with diminished renal function for a contrast enhanced MR.
 This imaging modality utilizes very high strength magnetic field to
generate images. There are potential hazards related to missile type
incidents where ferromagnetic objects are rapidly drawn into the MR
magnet. In addition, implanted objects in patients such as cochlear
implants, pacemakers and leads, aneurysm clips, and other medical
devices may interact with the magnetic field. Patients require rigorous
screening by the referring medical team and by the MR team to prevent
serious adverse events related to magnetic field related injuries.
THANK YOU