Introduction to Ultrasound Scanning

Diagnostic Ultrasound Advantages

- In most cases the exam is tolerated easily by most patients
- Patient preparation is easy compared to other imaging exams - No radiation exposure

- Capabilities to do portable exams

- Less expensive than other imaging modalities

Diagnostic Ultrasound Disadvantages

- Use is limited in the evaluation of dense structures, air filled structures or the gastrointestinal tract - Doesnt provide any information about organ function - Can not distinguish between benign and malignant tissue

Information Provided from Ultrasound

Ultrasound provides information concerning size, shape, echo pattern and position of organs and other structures
-The ultrasound professional must know the normal patterns of all organs, including shape, contour, texture, internal architecture, and relative position

-Any disruption of normal patterns suggests an anomaly or abnormality

Essentials for a good sonographic exam

Clinical considerations include:
Patient positions for specific exams

Transducer selection
Scanning techniques

Patient breathing techniques

These are the things you will learn in this class!!!

Labeling Sonographic Images

Ultrasound images are labeled as transverse or longitudinal for specific organs (ex: Long. Liver) Patient position should be included (ex: Rt. Decub)

**Labeling protocols will vary slightly from office to office**

Scan Planes

2 basic scan planes are used in abdominal ultrasound scanning. Sagittal / Longitudinal Patients body/organ is divided in into unequal right and left halves Transverse Patients body/organ is divided into unequal top and bottom halves

Longitudinal/Sagittal Scan Plane

Transducer placement for longitudinal scan plane

Long./Sagittal Monitor Correlation

In the longitudinal scan plane with patient supine: the top of the U/S monitor corresponds to the anterior anatomy of the patient the bottom of the U/S monitor corresponds to the posterior anatomy of the patient the left side of the screen corresponds to the anatomy closest to the patients head the right side of the screen corresponds to the anatomy closest to the patients feet

Transverse Scan Plane

Transducer position for the transverse scan plane

Transverse Monitor Correlation

In the transverse scan plane with the patient supine: The top of the U/S monitor corresponds to the anterior anatomy of the patient The bottom of the U/S monitor corresponds to the posterior anatomy of the patient The left side of the U/S monitor corresponds to the patients right side The right side of the U/S monitor corresponds to the patients left side

Prone Patient

At times it is necessary to image a patient prone

Prone Patient Monitor Correlation

In the longitudinal plane with the patient prone:

The top of the U/S monitor corresponds to the posterior anatomy of the patient The bottom of the U/S monitor corresponds to the anterior anatomy of the patient The left side of the screen corresponds to anatomy closest to the patients head The right side of the screen corresponds to the anatomy closest to the patients feet Note: The only thing that changes when imaging in the longitudinal plane when the patient is prone is the anterior and posterior anatomy (top and bottom of the screen)

Prone Patient Monitor Correlation

In the transverse plane with the patient prone:

The top of the U/S monitor correlates with the posterior anatomy of the patient The bottom of the U/S monitor correlates with the anterior anatomy of the patient The right side of the screen correlates with the anatomy on the patients right side The left side of the screen correlates with the anatomy on the patients left side

Sonographic Definitions

Echoes are the bright spots that make up an ultrasound image.

Echoes are the reflections of the sound beam Echoes represent the anatomy being evaluated with ultrasound Echoes vary in brightness giving valuable information about the organ

Sonographic Definitions

If a structure has a lot of echoes within it, it is called echogenic/hyperechoic

Echogenic/hyperechoic an echo

producing structure; reflects sound with a brighter intensity

Sonographic Definitions
Structures/organs that contain echoes that are exaggerated and extremely bright are referred to as hyperechoic
This usually suggests a very solid or dense structure or echo enhancement resulting from the sound beam passing through a fluid

Sonographic Definitions
The liver can be described as hyperechoic or moderately echogenic

liver Rt Kid

Sonographic Definitions

Hyperechoic liver lesion

Sonographic Definitions

Hyperechoic area posterior to gallbladder

Sonographic Definitions

Hypoechoic Low level echoes within a structure

Sonographic Definitions

Hypoechoic liver lesion

Sonographic Definitions

Hypoechoic renal cyst

Sonographic Definitions

The terms hypoechoic and hyperechoic are also used to compare different organs echogenicities.

If one organ appears brighter or contains more echoes than another organ then that organ is said to be hyperechoic or more echogenic than the other

Sonographic Definitions

In this image, the liver can be described as being hyperechoic to the Rt. Kidney or more echogenic than the Rt. Kidney The liver contains more and brighter echoes than the kidney

Sonographic Definitions

The terms hypoechoic and hyperechoic are also used to compare different organs echogenicities.

If one organ appears less bright or contains fewer echoes than another organ that organ is said to be less echogenic or hypoechoic to the other organ.

Sonographic Definitions

In this image the liver can be described as being hypoechoic to the pancreas or less echogenic than the pancreas

Liver

panc

Sonographic Definitiosn

The term anechoic/sonolucent (without echoes) is used to describe anatomy or structures that contain no echoes

Anechoic structures are represented on ultrasound as black Usually an anechoic structure is a fluid filled structure

Sonographic Terms

The normal gallbladder is an anechoic organ

Sonographic Definitions

Normal anechoic urinary bladder

Sonographic Definitions

Anechoic renal cyst

Sonographic Definitions

Two structures that have the same echogenicity are referred to as being isoechoic to each other Isoechoic is also used to describe an organ when normal parenchymal echogenicity pattern exists

Sonographic Definitions

In this image the liver and the lymph nodes present are isoechoic or isosonic

Sonographic Definitions
This liver can be described as being isoechoic since it exhibits a normal liver echo pattern

Sonographic Definitions

The terms homogeneous and inhomogeneous/heterogeneous are used to describe the texture of the anatomy being evaluated with ultrasound Homogeneous describes smooth uniform texture throughout a structure

Normal structures without pathology present will have a homogeneous texture

Sonographic Definitions

The normal liver should appear homogeneous

Sonographic Definitions

Heterogeneous / Inhomogeneous describes texture that is not uniform or smooth throughout

An organ or anatomy with a heterogeneous texture would indicate pathology or abnormality

Sonographic Definitions

This diseased liver would be described as inhomogeneous or heterogeneous

Sonographic Definitions

Once you become familiar with normal anatomy you will easily be able to spot abnormalities You may not know immediately what the specific pathology is, but you will know that something is wrong! Your mission in this class is to get to know normal sonographic anatomy!!!

Introduction to Scanning

Transducer Formats:

The format of an image is determined by the type of transducer being used There are three primary image shapes: Sector Linear Array

Curved Linear

Introduction to Scanning

Sector

Displayed as a pie shaped wedge. Advantage : the sector transducer has a smaller face, or footprint, which allows for scanning in small or tight spaces (i.e. between ribs or under xiphoid) Disadvantage : skin contact area is small and the image produced has a limited field of view of structures near the skin surface

Introduction to Scanning

Image produced with a sector transducer

Introduction to Scanning

Linear Array

Rectangular format Advantage : allows for imaging a wider field of view Disadvantage : large footprint not easily used in small areas

Introduction to Scanning
Image produced with a linear array transducer

Introduction to Scanning

Curved Linear Array

Also referred to as Convex Array

Displayed as a blunted pie shaped wedge The curved linear array is a good compromise between the sector and linear transducers The footprint is smaller than the linear transducer and the curve allows for better contact in small spaces It still allows for a wider field of imaging

Introduction to Scanning

Curved Linear Array

Also referred to as Convex Array

Introduction to Scanning
Image produced with a curved linear array transducer

Introduction to Scanning

Acoustic Window
Any medium or structure which transmits sound well

During an upper abdomen ultrasound exam the liver makes and excellent window for imaging the other abdominal structures The sonographer can take several images by simply sweeping the sound through the window, changing only the tilt or angle of the transducer

Introduction to Scanning

Transducer Manipulation

Sliding Rocking Tilting Rotating Compression

Introduction to Scanning

Sliding refers to gross movement of the transducer from one location to another and can be from or to any direction

Introduction to Scanning

Rocking the transducer towards a point of reference or away from it enables the sonographer to center the point on interest or extend the field of view in one direction or another. Also called In-plane motion because it allows for visualization of more anatomy in the original plane slice

Introduction to Scanning

Rocking

Introduction to Scanning

Illustration showing the change in the sound beam along the same plane when rocking

Introduction to Scanning

Tilting involves angling the transducer from side to side Also called cross-plane motion because it allows for visualization in other planes in the same axis

Introduction to Scanning

Illustration showing the change in planes of the sound beam when tilting

Artifacts

In most imaging fields artifacts usually degrade an image and are considered undesirable.
In ultrasound artifacts can be useful in identifying anatomy and pathology.

Artifacts

Posterior enhancement or through transmission the increased brightness of echoes behind a fluid filled structure.

When the sound beam travels through fluid, the echoes behind the fluid are exaggerated and appear brighter than the surrounding tissues.
Posterior enhancement indicates some fluid component is within the structure.

Artifacts

Posterior enhancement seen posterior to normal gallbladder

Artifacts
Posterior enhancement seen behind the two cysts located in the testicle

Artifacts

Shadowing opposite of posterior enhancement. Area behind the structure is hypoechoic or may even be anechoic.

Produced when the sound beam is completely reflected or absorbed by the structure being imaged.

Usually indicates a solid structure.

Artifacts

Shadow produced by gallstones

Artifacts

Shadowing caused by kidney stones

Artifacts

Gas or air-filled structures can reflect sounds and produce shadows.

Shadowing produced by an air-filled structure is described as a dirty shadow. The shadow behind a stone or a rib is sharply defined or described as a clean shadow.

Artifacts

Dirty shadow produced by air in bowel

Artifacts

Refraction Shadowing resulting from bending of the sound beam.

If an echo is not received by the transducer because of refraction, it is not displayed on the image. This often occurs at the edge of cysts. This is also referred to as edge shadowing

Artifacts
Refractive shadows seen on the edges of this breast cyst

Artifacts

Reverberation result due to the sound signal bouncing off a strong reflective interface.

Frequently seen when a fluid-filled structure is in close proximity to the transducer (anterior region of the bladder during a pelvic scan)
Appear as soft specular echoes in the anterior portion of the fluid structure.

Artifacts
Reverberation seen anterior bladder

Artifacts

Ring down or Comet Tail A type of reverberation artifact caused by a strong air interface or surgical clips

Demonstrated as multiple parallel spiral lines.

Artifacts

Ring down artifact seen in this transverse view of the thyroid. It occurs due to the air within the trachea.

Artifacts

Mirror artifact Occurs when the sound beam hits a curved structure, which focuses the sound beam like a mirror.

A mirror image is seen immediately behind the original reflector. Occurs frequently when scanning the diaphragm.

Artifacts
Mirror image artifact due to the diaphragm There appears to be liver tissue in the lungs

Artifacts
Mirror image artifact due to the diaphragm
The liver cyst is duplicated superior to diaphragm

Artifacts
Mirror image artifact due to the bladder wall
The bladder tumor and part of the bladder is duplicated outside of the bladder wall

Artifacts
Mirror image artifact due to the bladder wall
The bladder is duplicated outside of the bladder wall

Artifacts

Propogation Velocity Artifact Causes a misregistration of information resulting from the change in sound velocity as it passes through different densities.

If the sound is delayed, it is recorded as being positioned deeper than it actually is.

Artifacts
Propogation velocity artifact causes this diaphragm to look fractured

The sound travels slower through the liver tumor so the echoes posterior to the tumor are misplaced to appear deeper than they actually are

Artifacts

Movement artifact occurs when patient fails to hold his/her breath during imaging Imaged is distorted and blurry

The solution is to have patient take a deep breath in and hold it or ask him/her to stop breathing so that image can be taken.

Artifacts
Movement artifact seen due to patient inspiration and expiration The diaphragm is distorted

Assignments

There will be a quiz over todays material next Wednesday Read Chapter 5 on the Vascular System. Pg 101-122

References

Textbook of Diagnostic Ultrasonogaphy 6th edition Hagen-Ansert