1. ULTRASOUND IN MEDICAL DIAGNOSTICS
Prof. Ivo Hrazdira, MD., DSc.

2. WHAT IS ULTRASOUND?
Acoustic vibrations of frequencies higher than 20 kHz, non audible by human ear
According to the type of interaction with cells and tissues: ACTIVE ULTRASOUND – high intensity (applications in physical therapy and surgery) PASSIVE ULTRASOUND – low intensity (applications in medical diagnostics)

3. ACOUSTIC PARAMETERS Source: - FREQUENCY - INTENSITY
Medium: SPEED OF PROPAGATION ACOUSTIC IMPEDANCE ATTENUATION: - absorption scattering

4. DIAGNOSTIC ULTRASOUND
PHYSICAL PRINCIPLE ULTRASONIC WAVES PASSING THROUGH THE BODY ARE PARTIALLY REFLECTED ON TISSUE INTERFACES. REFLECTIONS (ECHOES) ARE RECEIVED, PROCESSED AND DISPLAYED

5. HISTORY OF ULTRASOUND PREPARATORY PERIOD
DOPPLER: PRINCIPLE OF FREQUENCY
SHIFT
BROTHERS CURIE: DISCOVERY OF
PIEZOELECTRIC PHENOMENON
LANGEVIN AND CHILOWSKI:
CONSTRUCTION OF THE FIRST ULTRASOUND
GENERATOR (SONAR)
SOKOLOV: BASIS OF NON-DESTRUCTIVE
ULTRASOUND MATERIAL TESTING

6. HISTORY OF DIAGNOSTIC ULTRASOUND
FIRST ATTEMPS
DUSSIK: HYPERPHONOGRAPIE (TRANSMISSION METHOD)
KEIDEL: HEART VOLUME MEASUREMENT
UCHIDA: A-MODE ENCEPHALOGRAPHY
WILD: TISSUE DIFFERENTIATION
WAGAI: BILL STONE DETECTION

7. HISTORY OF DIAGNOSTIC ULTRASOUND
FIRST ATTEMP - UNSUCCESSFUL
CLINICAL APPLICATIONS
D IMAGING (A- MODE)
ECHOCARDIOGRAPHY (M-MODE)
D - IMAGE OF ABDOMEN (B - MODE)
D - IMAGING IN OBSTETRICS
D - IMAGING IN OPHTHALMOLOGY
TRANSRECTAL EXAMINATION
FIRST CONTRAST IMAGING (SALINE)

8. HISTORY OF DIAGNOSTIC ULTRASOUND
CLINICAL APPLICATIONS (CONTINUED)
TRANSESOPHAGEAL EXAMINATION
BROAD-BAND TRANSDUCERS
D IMAGING IN OB/GYN
TRANSPULMONARY ECHOCONTRAST
AGENTS
NATIVE HARMONIC IMAGING
1998 – 4D (3D imaging in real time)

9. DIAGNOSTIC DEVICE ELECTROACOUTIC TRANSDUCER
MAIN PARTS OF A DIAGNOSTIC DEVICE
ELECTROACOUTIC TRANSDUCER
GENERATOR OF ELECTRIC IMPULSES
PROCESSING OF RECEIVED ECHOES
DISPLAY
RECORDING SYSTEM

10. DIAGNOSTIC DEVICES

11. TRANSDUCERS (imaging lines)

12. TRANSDUCERS sector convex linear
transvaginal/transrectal transesophageal

13. DIAGNOSTIC ULTRASOUND
IMAGING METHODS: A MODE (one-dimensional) B MODE (two-dimensional,
three-dimensional)
DOPPLER METHODS: CW PULSED COLOUR
COMBINED METHODS (duplex, triplex)

14. PRINCIPLE OF A- AND B- IMAGING

15. DIAGNOSTIC FREQUENCIES
2 - 6 MHz abdominal ultrasound, obstetrical and gynaecological exam, echocardiography, transcranial Doppler
MHz small parts, vascular Doppler, musculoskelatal ultrasound

16. DIAGNOSTIC FREQUENCIES
MHz ophthalmology, special vascular exam
MHz endoluminal exam, ultrasound biomicroscopy (ophthalmology, dermatology)

17. A- AND B- MODE IN OPHTHALMOLOGY

18. B- MODE IN ABDOMINAL REGION

19. B- MODE IN OBSTETRICS

20. B- MODE IN MUSCULOSKELETAL ULTRASOUND
Meniscal Tear

21. B- AND M- MODE IN CARDIOLOGY

22. PROGRESS IN ULTRASONOGRAPHY
IMPROVED IMAGE DISPLAY
- digital technology
- 3D/4D imaging
IMPROVED SIGNAL DETECTION
- echo-enhancing agents
- harmonic imaging

23. PROGRESS IN ULTRASONOGRAPHY
NOVEL METHODS
- anisotropic imaging
- perfusion imaging
- elastography
NOVEL APPLICATIONS
- intraoperative
- intraluminal

24. DIGITAL TECHNOLOGY BROADBAND SCANHEADS/ BROADBAND BEAMFORMING
- captures full tissue signature
EXTENDED SIGNAL PROCESSING
- digitally preserves entire signal
TISSUE SPECIFIC IMAGING
- improves signal/noise ratio for detection
of small, low-contrast lesions

25. DIGITAL TECHNOLOGY

26. BROADBAND TECHNOLOGY

27. BROADBAND TECHNOLOGY IMAGES

28. WHAT ARE ECHOCONTRAST AGENTS?
AIR OR GAS MICROBUBBLES, FREE OR INCAPSULATED IN A POLYMER COVER
ACCORDING TO THEIR HIGHER DIFFERENCE IN ACOUSTIC IMPEDANCE, CONTRAST AGENTS ENHANCE THE ECHOGENICITY OF THE BODY SPACE IN WHICH THEY WERE INTRODUCED

29. ECHOCONTRAST AGENTS
CATEGORY OF ECHOCONTRAST AGENTS:
GAS BUBBLES INTRODUCED INTO THE ORGANISM (ECHOVIST, LEVOVIST, ALBUNEX, ECHOVIEW)
GAS BUBBLES FORMED IN THE ORGANISM (ECHOGEN)

30. ECHOCONTRAST AGENTS IN VASCULAR IMAGING
- enhance weak signals resulting from deep vessels or slow flow (hyperaemia, ischaemia)
- improve signals from malignant neovascularization
IN NON-VASCULAR IMAGING
- increase the reflectivity of particular normal or pathologic tissues (targeted agents)
- delineate body cavities and communications

31. INCAPSULATED BUBBLES (scanning electronmicrograph)

32. HARMONIC IMAGING
NEW MODE OF ULTRASOUND IMAGING, IN WHICH THE FUNDAMENTAL FREQUENCY OF RETOURNING ECHOES IS SUPPRESSED AND SIGNALS OF HARMONIC FREQUENCY ARE RECEIVED, PROCESSED AND DISPLEYED

33. FORMS OF HARMONIC IMAGING
CONTRAST HARMONIC IMAGING
microbubbles of echo enhancing agents are able to resonate and emit harmonic signal
NATIVE HARMONIC IMAGING
harmonic signal is produced by oscillation of tissue structures due to the non-linear propagation of ultrasound

34. PRINCIPLE OF HARMONIC IMAGING
transmission
2.5 MHz
5 MHz
receiving 5
2.5
supression

35. HARMONIC IMAGING
stone
FUNDAMENTAL HARMONIC

36. 3-D IMAGING
3-D IMAGING TECHNOLOGY ALLOWS PHYSICIANS TO VIEW PATIENT´S NORMAL AND PATHOLOGIC ANATOMY AS A VOLUME IMAGE
IT IS SUGGESTED THAT 3-D IMAGING WILL PROVIDE A CENTRAL INTEGRATING FOCUS IN ULTRASOUND DIAGNOSTICS

37. 3-D IMAGING
PHYSICAL PRINCIPLE:
THE TRANSDUCER IS MOVED DURING EXPOSURE (linear shift, swinging, rotation)
RECEIVED ECHOES ARE STORED IN THE MEMORY
THE IMAGE IN THE CHOSEN PLAIN IS RECONSTRUCTED MATHEMATICALY

38. 3D IMAGING

39. 3-D COLOUR DOPPLER SONOGRAPHY
REPRESENTS A COMBINATION OF 3-D AND POWER DOPPLER TECHNOLOGY: transducer elements are electronically or manually sectored during exposure
3D CDS ALLOWS DEPICTION OF THE OVERALL VASCULARITY IN THE AREA OF INTEREST (esp. tumours)

40. 3D COLOUR DOPPLER IMAGING

41. ANISOTROPIC IMAGING PHYSICAL PRINCIPLE
IN ULTRASOUND TECHNOLOGY, ANISOTROPY REPRESENTS A DIRECTIONAL DEPENDENCY OF BACKSCATTERED WAVES
THIS MODALITY CAN BE USED FOR DIFFERENTIATING NORMAL ANISOTROPIC TISSUES FROM ISOTROPIC ABNORMALITIES

42. ANISOTROPIC IMAGING AREAS OF CLINICAL APPLICATIONS
CARDIOLOGY: MYOCARDIUM EXAMINATION
NEPHROLOGY: EXAMINATION OF RENAL CORTEX
MUSCULOSKELETAL ULTRASOUND: EXAMINATIONS OF TENDONS AND CARTILAGES

43. ELASTOGRAPHY METHOD FOR IMAGING THE ELASTIC PROPERTIES OF TISSUES
REPRESENTS AN IMAGING ANALOGY TO PHYSICAL EXAMINATION BY TOUCH
DIFFERENCES IN MECHANICAL PROPERTIES OF TISSUES CAN BE IMAGED IN 2D- OR 3D- COLOUR-SCALE MANNER

44. ELASTOGRAPHY
MODEL MIMICING CONTRAST LESION IN PROSTATE

45. ELASTOGRAPHY (benign and malignant lesion of the breast)

46. ENDOLUMINAL IMAGING Transversal view of oesophageal sphincter
1 mucosa, 2 submucosa, 3 circular muscle,
4 intermuscular connective tissue,
5 longitudinal muscle, 6 adventitia
2D and 3D image of advanced
oesophageal cancer

47. DOPPLER ULTRASOUND A.Ch. Doppler (1803-1853)
DOPPLER PRINCIPLE (1842) - frequency shift due to the movement of the source or reflector
DOPPLER METHODS SERVE IN MEDICINE FOR: DETECTION OF TISSUE MOVEMENTS MEASUREMENT OF BLOOD FLOW VELOCITY AND DIRECTION

48. MILESTONES OF DOPPLER ULTRASOUND
CONTINUOUS WAVE DOPPLER (CWD)
PULSE WAVE DOPPLER (PWD)
TRANSCRANIAL DOPPLER (TCD)
COLOUR FLOW MAPPING (CFM)
CONTRAST HARMONIC IMAGING (CHI)
POWER DOPPLER (PD)
TISSUE DOPPLER IMAGING (TDI)

49. DOPPLER EQUATION 1 (Doppler shift)

50. DOPPLER EQUATION 2 (velocity)

51. CONVENTIONAL DOPPLER METHODS

52. FLOW DIRECTION

53. MAIN VELOCITY CURVES
Low vascular impedance
High vascular impedance

54. COLOUR FLOW MAPPING (right renal artery)

55. COLOUR FLOW MAPPING (common carotid artery)

56. COLOUR FLOW MAPPING

57. NEW COLOUR DOPPLER IMAGING MODALITIES
POWER DOPPLER (Colour Doppler Energy, Colour Doppler Angio)
TISSUE DOPPLER IMAGING (TDI)
3-D COLOUR DOPPLER SONOGRAPHY (3D CDS)

58. POWER DOPPLER
NEW TECHNOLOGY OF DOPPLER SIGNAL PROCESSING, IN WHICH ITS ENERGY ISTEAD OF ITS AMPLITUDE IS RECORDED
THE ENERGY IS RELATED TO THE SQUARE OF THE AMPLITUDE OF THE SIGNAL
USING THIS TECHNOLOGY, EVEN WEAK SIGNALS (CORRESPONDING TO LOW FLOW RATES) CAN BE RECORDED

59. DOPPLER SIGNAL ENERGY

60. POWER DOPPLER (renal perfusion)

61. POWER DOPPLER (increased thyroid perfusion)

62. POWER DOPPLER (kinking of internal carotid artery)

63. POWER DOPPLER - more complete displaying of the vascular bed
ADVANTAGE
- detection of very low blood flow
- more complete displaying of the vascular bed
- absence of aliasing and only little angle
dependence
DISADVANTAGE
- loss of directional and partial loss of velocity
information

64. TISSUE DOPPLER IMAGING
NEW COLOUR DOPPLER IMAGING MODALITY IN WHICH THE DOPPLER SIGNAL IS DERIVED FROM SLOW TISSUE MOVEMENTS
THE SYSTEM SUPRESSES FAST VELOCITIES OF BLOOD FLOW AND RECORDS ONLY SLOW MOVEMENTS IN THE RANGE mm/s

65. CLINICAL IMPORTANCE OF TDI
ASSESSMENT OF MYOCARDIUM MOVEMENTS DURING HEART CONTRACTION
ASSESSMENT OF DISTENSIBILITYAND COMPLIANCE OF VESSEL WALL
ASSESSMENT OF SKELETAL MUSCLES CONTRACTIBILITY AND TENDON MOVEMENTS

66. TDI - HEART Colour imaging of blood flow
TDI- Colour imaging of heart movements

67. TDI - ARTERY

68. FUTURE OF ULTRASONOGRAPHY
In the medical imaging world, it is hard to beat ultrasound in following terms:
COST - EFFECTIVENESS
RANGE OF APPLICATIONS
SAFETY

69. FUTURE OF ULTRASONOGRAPHY
ACCORDING TO RECENT ADVANCES IN POWER DOPPLER, 3-D IMAGING, CONTRAST AGENTS, HARMONIC IMAGING AND INTERVENTIONAL APPLICATIONS, ULTRASONOGRAPHY BECOMES THE PREFERRED DIAGNOSTIC IMAGING MODALITY OF THE 21TH CENTURY