A review of Doppler ultrasound quality assurance protocols and test devices

In this paper, an overview of Doppler ultrasound quality assurance (QA) testing will be presented in three sections. The first section will review the different Doppler ultrasound parameters recommended by professional bodies for use in QA protocols. The second section will include an evaluation and critique of the main test devices used to assess Doppler performance, while the final section of this paper will discuss which of the wide range of test devices have been found to be most suitable for inclusion in Doppler QA programmes. Pulsed Wave Spectral Doppler, Colour Doppler Imaging QA test protocols have been recommended over the years by various professional bodies, including the UK's Institute of Physics and Engineering in Medicine (IPEM), the American Institute for Ultrasound in Medicine (AIUM), and the International Electrotechnical Commission (IEC). However, despite the existence of such recommended test protocols, very few commercial or research test devices exist which can measure the full range of both PW Doppler ultrasound and colour Doppler imaging performance parameters, particularly quality control measurements such as: (i) Doppler sensitivity (ii) colour Doppler spatial resolution (iii) colour Doppler temporal resolution (iv) colour Doppler velocity resolution (v) clutter filter performance and (vi) tissue movement artefact suppression. In this review, the merits of the various commercial and research test devices will be considered and a summary of results obtained from published studies which have made use of some of these Doppler test devices, such as the flow, string, rotating and belt phantom, will be presented.     

Accuracy of colour Doppler ultrasound velocity measurements in small vessels

Colour Doppler ultrasound offers the possibility of imaging small vessels not visible by B-mode alone. The colour Doppler image of velocities allows the course of small vessels to be imaged in the X-Y plane of the scan provided the Doppler frequency shift is of sufficient magnitude. This permits alignments of the Doppler cursor, allowing angle correction to provide true velocity measurements from the Doppler shift obtained. Before attempting to make velocity measurements, however, it is essential to be aware of the possible error in the Z plane caused by the thickness of the Doppler sample volume. To quantify this source of error, hydrophone and flow-rig measurements were performed on an Acuson 128 colour Doppler scanner with both 5 MHz linear-array and 3.5 MHz phased-array transducers. Measurements of the transmitted pulses using a point hydrophone showed that both probes employ approximately 3.5 MHz Doppler pulses (in both colour and pulsed Doppler modes). The two transducers have the same axial resolution. In colour Doppler mode the axial length of the sample volume increases automatically with depth by up to 0.5 mm. Measurements of colour and pulsed Doppler signal strength were obtained in a controlled flow rig. Both transducers produced accurate colour flow images of the phantom at their optimum depths; flow velocity errors due to Z-plane thickness are < 5%. There was, however, substantial error outside these optimum conditions (up to 20%).     

Preoperative color Doppler assessment in planning of anterolateral thigh flaps

The anterolateral thigh flap has many advantages, but it has not yet achieved widespread use because the perforators exhibit considerable anatomical variation and their locations are difficult to predict preoperatively. The authors performed a prospective study to investigate whether acoustic Doppler flowmetry and color Doppler ultrasonography were helpful for preoperative localization of the perforators in anterolateral thigh flaps. Ten patients scheduled for anterolateral thigh flap surgery were examined preoperatively with both acoustic Doppler flowmetry and color Doppler ultrasonography, and all points where the perforators seemed to penetrate the fascia lata were mapped. The actual perforating points were identified intraoperatively and were compared with the preoperatively mapped points. Fifteen perforators were detected in 10 patients. The concordance rate with acoustic Doppler flowmetry was 40 percent (95 percent confidence interval, 15 to 68 percent; p = 0.05). In contrast, the concordance rate with color Doppler ultrasonography was 100 percent (95 percent confidence interval, 81 to 100 percent; p = 0.05). Color Doppler examination was significantly more accurate than acoustic Doppler examination (determined by the binomial test; p < 0.0014). Three-dimensional anatomical information around the perforators was further useful in elevating flaps. The authors conclude that color Doppler examination can accurately identify the perforators and is useful for planning in anterolateral thigh flap surgery, whereas acoustic Doppler examination is unreliable.     

A new approach for the evaluation of the severity of coarctation of the aorta using Doppler velocity index and effective orifice area: in vitro validation and clinical implications

Early detection and accurate estimation of COA severity are the most important predictors of successful long-term outcome. However, current clinical parameters used for the evaluation of the severity of COA have several limitations and are flow dependent. The objectives of this study are to evaluate the limitations of current existing parameters for the evaluation of the severity of coarctation of the aorta (COA) and suggest two new parameters: COA Doppler velocity index and COA effective orifice area. Three different severities of COAs were tested in a mock flow circulation model under various flow conditions and in the presence of normal and stenotic aortic valves. Catheter trans-COA pressure gradients and Doppler echocardiographic trans-COA pressure gradients were evaluated. COA Doppler velocity index was defined as the ratio of pre-COA to post-COA peak velocities measured by Doppler echocardiography. COA Doppler effective orifice area was determined using continuity equation. The results show that peak-to-peak trans-COA pressure gradient significantly increased with flow rate (from 83% to 85%). Peak Doppler pressure gradient also significantly increased with flow rate (80-85%). A stenotic or bicuspid aortic valve increased peak Doppler pressure gradient by 20-50% for a COA severity of 75%. Both COA Doppler velocity index and COA effective orifice area did not demonstrate significant flow dependence or dependence upon aortic valve condition. As a conclusion, COA Doppler velocity index and COA effective orifice area are flow independent and do not depend on aortic valve conditions. They can, then, more accurately predict the severity of COA.     

Shear-layer detection in poststenotic flow by spectrum analysis of Doppler signals

Spectrum analysis of the Doppler signals was performed 0.5 tube diameters downstream from an axisymmetric constriction with an area reduction of 80 percent in steady flow at a jet Reynolds number of 2840. Both pulsed and continuous wave (CW) Doppler spectra showed significant reverse flow components in the separated flow. The pulsed Doppler spectra exhibited sudden changes when the sample volume crossed the shear layer between the center jet and the separated flow. A power spectrum equation was theoretically derived from continuity of flow to define the Doppler shift frequency for the shear layer velocity. The CW Doppler spectrum showed a minimum spectrum density at a frequency which equalled the shear layer Doppler shift frequency derived from the equation. The pulsed spectra exhibited the sudden changes at the same frequency as well.     

Standardized ultrasound evaluation of carotid stenosis for clinical trials: University of Washington Ultrasound Reading Center

Introduction

Serial monitoring of patients participating in clinical trials of carotid artery therapy requires noninvasive precision methods that are inexpensive, safe and widely available. Noninvasive ultrasonic duplex Doppler velocimetry provides a precision method that can be used for recruitment qualification, pre-treatment classification and post treatment surveillance for remodeling and restenosis. The University of Washington Ultrasound Reading Center (UWURC) provides a uniform examination protocol and interpretation of duplex Doppler velocity measurements.

Methods

Doppler waveforms from 6 locations along the common carotid and internal carotid artery path to the brain plus the external carotid and vertebral arteries on each side using a Doppler examination angle of 60 degrees are evaluated. The UWURC verifies all measurements against the images and waveforms for the database, which includes pre-procedure, post-procedure and annual follow-up examinations. Doppler angle alignment errors greater than 3 degrees and Doppler velocity measurement errors greater than 0.05 m/s are corrected.

Results

Angle adjusted Doppler velocity measurements produce higher values when higher Doppler examination angles are used. The definition of peak systolic velocity varies between examiners when spectral broadening due to turbulence is present. Examples of measurements are shown.

Discussion

Although ultrasonic duplex Doppler methods are widely used in carotid artery diagnosis, there is disagreement about how the examinations should be performed and how the results should be validated. In clinical trails, a centralized reading center can unify the methods. Because the goals of research examinations are different from those of clinical examinations, screening and diagnostic clinical examinations may require fewer velocity measurements.     

基于血流多普勒原理的血压测量系统设计

血流信号的采集可基于超声多普勒技术。利用多普勒超声探头在肢体主动脉脉搏处采集到血流多普勒频移信号,对信号电压进行放大,一方面直接输入扬声器转变为音频信号,得到多普勒音;同时用频率/电压变换器LM331变换多普勒频移信号,得到脉搏波信号。基于此原理,设计了使用无创、直观的方法获得肢体血流参数,并经PC机处理,最终在显示器上显示脉搏波形和血压数值的方法。     

Rheological and flow properties of blood investigated by ultrasound

Ultrasonic waves of 1-15 MHz frequencies easily propagate through soft biological tissues, thus providing qualitative and quantitative information on mechanical and flow properties of blood and red blood cell (RBC) suspensions. Two types of techniques allow to investigate blood behaviors: echographic devices via amplitude detection and Doppler effect based devices via frequency detection of the ultrasonic signal. When ever B mode serves to construct images of tissue slabs from the ultrasonic backscattering coefficient and can give qualitative information on the mechanical properties of blood, A-mode allows to quantify the ultrasonic backscattering coefficient. Ultrasonic Doppler modes also provide both qualitative and quantitative information on blood flow velocity: continuous and pulsed Doppler modes provide curves of blood flow versus time when color Doppler and power Doppler imaging visualize blood flowing in human vessels. Association of echographic and Doppler modes to investigate simultaneously structure and velocity of blood is commercially available. Some examples of results given by such ultrasonic techniques that contribute to characterize, both in vitro and in vivo, structure and flow properties of blood or red blood cell (RBC) suspensions are presented.     

Limitations of Doppler echocardiography for the post-operative evaluation of aortic coarctation.

Doppler blood flow measurements and derived pressure differences, through the Bernoulli equation, are used in the diagnosis of aortic coarctation, a congenital stenosis distal to the left subclavian artery. Doppler velocities remain elevated at the coarctation site after successful repair of coarctation, leading to high Doppler derived pressure differences without significant arm-leg pressure differences. We studied this apparent contradiction of two diagnostic methods, in vivo using patient and control data, and in vitro using a hydraulic model. Clinical and echocardiographic data from 31 patients, aged 13.0 +/- 4.0, 10.5 +/- 4.7 yr after coarctectomy by end-to-end anastomosis, and 18 age-matched healthy subjects were reviewed. Doppler peak velocities at the aortic isthmus were elevated in patients (2.2 +/- 0.4 vs. 1.2 +/- 0.2m/s, P < 0.001), corresponding to significant Doppler differences (20 +/- 7 mmHg), however, without significant arm-leg pressure differences. In all patients, a mild anatomic stenosis could still be observed. Local stiffness was increased. The hypothesis that the less distensible surgical scar in post-coarctectomy patients leads to a significant dynamic obstruction in systole was validated in a latex model of the aorta. Rigid rings (0.5-1.5 cm), matching the unloaded aortic diameter, were mounted around the aorta. Under loading conditions, Doppler peak velocities increased by 40 +/-7%, yielding Doppler differences of 21 +/- 3 mmHg, without a significant pressure drop. An alternative expression to calculate pressure differences, using both velocity and geometric information, was validated in the model. In conclusion, post-operatively, Doppler velocities remain elevated due to a mild anatomical and significant dynamic narrowing, but the specific geometry, resembling a tubular hypoplasia rather than an abrupt stenosis, permits an almost complete pressure recovery explaining the occurrence of Doppler differences in disagreement with the negligible arm-leg pressure difference.     

Echocardiography.

Imaging echocardiography is an important extension of the clinical examination and will answer most questions in an emergency-for example, whether an enlarged cardiac shadow on the chest radiograph represents ventricular dilatation or an effusion. Doppler ultrasonography is essential for hospitals with an interest in cardiology because it provides direct haemodynamic data that are complementary to imaging. It requires more skill than imaging and may also be time consuming. Colour flow Doppler mapping is speedy and simple to use and aids the interpretation of continuous wave Doppler. It is therefore a natural companion to conventional Doppler, but there would have to be a high clinical load to justify its purchase.     

An audit of a hospital-based Doppler ultrasound quality control protocol using a commercial string Doppler phantom

Results from a four-year audit of a Doppler quality assurance (QA) program using a commercially available Doppler string phantom are presented. The suitability of the phantom was firstly determined and modifications were made to improve the reliability and quality of the measurements. QA of Doppler ultrasound equipment is very important as data obtained from these systems is used in patient management. It was found that if the braided-silk filament of the Doppler phantom was exchanged with an O-ring rubber filament and the velocity range below 50 cm/s was avoided for Doppler quality control (QC) measurements, then the maximum velocity accuracy (MVA) error and intrinsic spectral broadening (ISB) results obtained using this device had a repeatability of 18 ± 3.3% and 19 ± 3.5%, respectively. A consistent overestimation of the MVA of between 12% and 56% was found for each of the tested ultrasound systems. Of more concern was the variation of the overestimation within each respective transducer category: MVA errors of the linear, curvilinear and phased array probes were in the range 12.3–20.8%, 32.3–53.8% and 27–40.7%, respectively. There is a dearth of QA data for Doppler ultrasound; it would be beneficial if a multicentre longitudinal study was carried out using the same Doppler ultrasound test object to evaluate sensitivity to deterioration in performance measurements.     

Implementation of a field programmable gate array based transcranial Doppler ultrasound system using pulse compression techniques

A field programmable gate array (FPGA) based hardware platform that is used to implement a digital, multi-gate pulsed Doppler ultrasound system for transcranial Doppler (TCD) use is described. The Doppler audio signal is extracted from the digitised radio-frequency signal by matched filtering and suitable sampling. The system was configured to acquire Doppler signals from 16 depth locations and to display Doppler signal power versus depth as well as a sonogram from a user specified depth. The signal-to-noise performance of the system was comparable with that of a commercially available TCD unit for equivalent pulse repetition frequency and sample volume settings.The flexibility of the platform was used to demonstrate the feasibility of using coded transducer excitation and pulse compression techniques to improve axial resolution compared to a non-coded implementation. The axial resolution improvement was demonstrated using a flow phantom and measured using a vibrating wire phantom. The measured resolutions were 9.1 and 2.4 mm for the conventional and coded implementations, respectively. The reduction in signal-to-noise ratio of approximately 5 dB associated with the configuration using coded excitation was attributable to the frequency response characteristics of the transducer rather than the processing technique used. This work demonstrates both the flexibility associated with an FPGA implementation of a Doppler ultrasound system and the potential for coded excitation to improve axial resolution in TCD systems.     

Measurement of mucosal blood flow in the canine intestine with laser doppler velocimetry

Laser Doppler velocimetry is a technique for continuous estimation of changing blood flow in the surface of a tissue and does not require invasion of the circulation. This technique is based upon the Doppler principle that a shift in the frequency of an electromagnetic wave emitted or reflected from a moving object is proportional to the velocity of the object. The capacity of Laser Doppler velocimetry to estimate changes in intestinal mucosal blood flow was tested in a canine free flow preparation. In anesthetized dogs in which a segment of ileum was isolated, simultaneous measurements of instantaneous changes in total blood flow (measured with the electromagnetic blood flow meter) and instantaneous changes in presumed mucosal blood flow (using laser Doppler velocimetry) were obtained. Determinations were made during conditions of rest, prostacyclin induced vasodilation and norepinephrine induced vasoconstriction. Changes in laser Doppler velocimeter readings were qualitatively similar to and temporally related to changes in total blood flow to the gut segment during administration of the vasoactive drugs. The magnitude and direction of changes with the two measurements were significantly correlated. Stabilizing the laser probe on the mucosal surface to ensure reproducible readings proved technically difficult. Pharmacologically induced changes in laser Doppler velocimeter estimated changes in flow were more readily correlated with changes in electromagnetic flow meter readings than were control values obtained with the two methods.     

稳恒流下腹主动脉旁瘤超声多普勒血流信号的仿真分析

腹主动脉旁瘤超声多普勒血流信号的仿真研究,可以为采用超声多普勒技术检测腹主动脉旁瘤的形成、生长过程和估计动脉旁瘤瘤体大小提供指导。先通过有限元数值计算方法得到稳恒流下腹主动脉旁瘤区域内的血液流场分布,然后采用余弦叠加的合成方法仿真出相应的超声多普勒血流信号,最后对仿真信号进行频谱分析,计算其平均频率,并研究它与腹主动脉旁瘤瘤体大小的关系。结果表明：当动脉旁瘤较小时,平均频率的幅度变化较小;当动脉旁瘤较大时,平均频率的幅度变化较大。因此,采用平均频率的幅度变化可以在一定程度上估计动脉旁瘤的瘤体大小。     

Doppler echocardiographic estimation of left ventricular end-diastolic pressure after MI in rats

The spectral Doppler mitral flow pattern, alone or combined with tissue Doppler mitral annulus velocity, can be used to predict left ventricular (LV) filling pressure in humans, whereas invasive hemodynamic measurements are still required in the rat. This study was undertaken to assess whether LV end-diastolic pressure (LVEDP) can be estimated using Doppler echocardiography in the rat after myocardial infarction (MI). Thirty-seven rats (23 rats with MI after left coronary artery ligation and 14 sham-operated rats) were evaluated 3 mo after surgery with echo-Doppler and invasive hemodynamic measurements. Pulse wave spectral Doppler at the mitral valve tip was used to measure the E wave, the E wave deceleration time (DT), and the A wave; spectral Doppler tissue imaging was used to measure the early diastolic lateral mitral annulus velocity (E(a)). We found weak correlations between LVEDP and the peak velocity of the early mitral inflow (E), E/peak velocity of the late mitral inflow, and DT, and strong correlations with E(a) and especially with E/E(a) [R(2) = 0.89, LVEDP (in mmHg) = 0.987E/E(a) - 4.229]. Longitudinal followup of a subgroup of rats with MI revealed a marked rise of E/E(a) between days 7 and 21 in rats with heart failure only. We conclude that Doppler echocardiography can be used for serial assessment of LV diastolic function in rats with MI.     

Evaluation of biological effects induced by diagnostic ultrasound in the rat foetal tissues

In recent years, there has been growing interest in estimating the degree of heating caused by the diagnostic ultrasound in clinical practice. Both theoretical and experimental methods have been suggested for estimating the heating potential, or thermal hazard, of diagnostic ultrasound. Aim of this study was to evaluate in vivo effects of ultrasound exposure of variable duration (from 10 up to 20 min) with commercially available imaging systems commonly used for diagnostic imaging. Numerical results related to the thermal effect are obtained by simulation program based on B-mode (scanning) and Doppler (non-scanning). To investigate the biological effects of the ultrasound exposure to the brain and liver tissues, the antioxidant enzyme activity and thiobarbituric acid reactive substances (TBARS) of the tissues were evaluated. In liver tissue, as a lipid peroxidation index, TBARS levels very significantly increase in Doppler group compared to control. However, in B-mode, TBARS levels are the same with the control group. Use of B-mode in foetal tissue is more reliable than Doppler mode because temperature rise is very small compared to the Doppler mode. On the other hand, the antioxidant enzyme activities tend to increase in B-mode and Doppler groups compared to the control group as a defensive mechanism. In the brain tissue, lipid peroxidation is increased slightly in B-mode compared to the control group. This situation is related to the molecular structure of the brain tissue because of its high lipid concentration. In brain tissue, the antioxidant enzyme activities and lipid peroxidation were significantly increased, such as liver tissue in Doppler groups. Doppler ultrasound may produce harmful effects in rat foetus liver and brain tissues as a result of the high temperature rises.     

Postnatal Anthropometric and Body Composition Profiles in Infants with Intrauterine Growth Restriction Identified by Prenatal Doppler

IntroductionInfant anthropometry and body composition have been previously assessed to gauge the impact of intrauterine growth restriction (IUGR) at birth, but the interplay between prenatal Doppler measurements and postnatal development has not been studied in this setting. The present investigation was performed to assess the significance of prenatal Doppler findings relative to postnatal anthropometrics and body composition in IUGR newborns over the first 12 months of life.ResultsA total of 48 pregnancies qualifying as IUGR were studied. Doppler parameters were normal in 26 pregnancies. The remaining 22 deviated from normal, marked by an Umbilical Artery Pulsatility Index (UA-PI) >95^th centil or Cerebro-placental ratio (CPR) <5^th centile. No significant differences emerged when comparing anthropometry and body composition at each time point, in relation to Doppler findings. Specifically, those IUGR newborns with and without abnormal Doppler findings had similar weight, length, body mass index, lean and fat mass, and bone mineral content throughout the first 12 months of life. In a separate analysis, when comparing IUGR newborns by Doppler (abnormal UA-PI vs. abnormal CPR), anthropometry and body composition did not differ significantly.ConclusionsInfants with IUGR maintain a pattern of body composition during the first year of life that is independent of prenatal Doppler findings. Future studies with larger sample sizes and correlating with hormonal status are warranted to further extend the phenotypic characterization of the various conditions now classified under the common label of IUGR.     

Monitoring free flaps using the laser Doppler flowmeter: five-year experience

Over a 5-year period, 232 microvascular composite-tissue transfers to the head and neck, trunk, and extremities were monitored using the laser Doppler flowmeter. Thirteen free flaps (5.6 percent) developed vascular complications, all within 4 days after surgery. The laser Doppler flowmeter detected vascular compromise in all cases with no false positives or negatives. Failure to monitor the flap according to protocol by nursing staff occurred in one patient, which led to a delay in detection of venous compromise and subsequent flap loss. The salvage rate was 69.2 percent, leading to an overall flap viability of 98.3 percent. Our series of free-flap monitoring using the laser Doppler flowmeter is the largest reported to date. Review of the English literature shows consistent support by numerous clinical series for the use of the laser Doppler as a valuable postoperative monitor after free-flap transfers.     

Assessment of dose & optimisation of image quality in the XVI cone beam CT system

Background: Colour and power Doppler have become integral parts of many clinical ultrasound investigations and, due to this, refinements are made to the current technology to ensure accurate results for clinical perception of image quality.Method: The aim of this study was to modify and evaluate existing Doppler Ultrasound devices for the assessment of Colour Doppler spatial resolution. In this study a convention flow phantom design was modified to have a set of line pairs of varying     

超声检查在乳腺癌诊断中价值的探讨

目的：探讨二维及彩色多普勒超声在乳腺癌诊断方面的临床应用价值。方法：对60例经手术病理证实的乳腺肿块病例的二维及彩色多普勒超声检查与病理结果进行回顾性分析。结果：乳腺癌诊断中,大多数恶性肿块表现为形态不规则、边缘粗糙、边界不清、内部回声不均匀、后方回声衰减。恶性肿块的血流显示率明显高,血流分布以Ⅱ、Ⅲ级为主。结论：二维声像图及彩色多普勒在乳腺癌诊断方面有较高的临床应用价值。由于良恶性肿物的影像互有交叉,其诊断符合率并非是100%。须两者联合应用,综合分析,方可提高超声对乳腺良恶性肿块的诊断符合率。