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Ultrasound Physics and Instrumentation 6th Edition

The author and publisher of this book have used their best efforts in preparing this book Their efforts include the development research and testing of the theories and problems to determine their effectiveness The author and publisher shall not be liable in any event for incidental or consequential damages in connection with or arising out of the furnishing performance or use of these programs This work is protected by United States copyright laws Dissemination or sale of any part of this work including on the World Wide Web destroys the integrity of the work and is not permitted A Cataloging In Publication Record is available from the Library of Congress Printed in the United States of America Last Digit is the print number 9 8 7 6 5 4 3 2 1 ISBN 13 978 1 933250 15 1 Copyright 2021 by Miele Enterprises LLC All rights reserved No part of this book may be reproduced in any form or by any means electronic or mechanical including photocopy recording or any information storage and retrieval system without permission in writing from Miele Enterprises LLC and Pegasus Lectures Inc

Preface WHAT S NEW IN THIS EDITION Enhanced Features Chapter introductions which detail the clinical significance of the physics concepts and provide critical learning objectives New images and animations Exam Tip CheckPoints reinforce concepts commonly tested on board exams Author s Notes provide additional conceptual perspectives based on Frank Miele s years of experience Access to digital eBook with additional chapters of advanced concepts New 6e Online Extras including Library of additional images and original animations Clarifying Clips offer verbal explanations of challenging concepts Interactive Exercises and Conceptual Questions with immediate feedback and scoring Additional chapters regularly updated with new content Instructor Dashboard allows college instructors to monitor the progress of each student quickly identifying areas of content weakness New and Updated Content CMUT transducer technology Bioeffects and quality assurance New beamformer and image generation techniques Physics of stress and strain Advanced ultrasound system operation Artificial intelligence AI and its applications in ultrasound and medicine Effects of new monitor technology on ultrasound viewing Ultrafast Doppler spatiotemporal filtering and other Doppler techniques Color Doppler and surface rendering Artifacts related to new medical devices New approved applications of ultrasound New elastography techniques Image optimization based on physics vii

viii Ultrasound Physics Instrumentation Book Structure Learning Objectives Levels Each chapter begins with a quick glance at the content with an outline of learning milestones Topics are divided into levels allowing readers to progress at a pace appropriate to their background Checkpoints Exam tip checkpoints are provided throughout the book to highlight important concepts often seen on board exams Author s Notes LEVEL 1 BASIC ULTRASOUND PHYSICS Level 1 material focuses on the underlying physics and basic concepts critical for developing skill in the use of diagnostic ultrasound Level 1 presumes no knowledge other than the basic abilities that come from general schooling This level also serves as a good refresher for people who have ultrasound experience but weaker backgrounds in physics and basic mathematics LEVEL 2 BOARD LEVEL Level 2 material covers basic topics often outlined on the credentialing exams and is intended to generate a more profound understanding of the concepts The relationship of the physics fundamentals to the quality of the diagnostic ultrasound should be understood In other words understanding Level 2 should not only prepare you for your board exams but also result in better patient care LEVEL 3 ADVANCED TOPICS Level 3 material contains advanced topics newer ultrasound techniques and higher level material for those who want to be challenged At times Level 3 will also contain specific applications of the physics to a specialty area such as cardiac vascular or general ultrasound Key Concepts Critical concepts are summarized to improve comprehension and enhance retention of material Notes from the author provide additional conceptual perspectives based on Frank Miele s years of ultrasound experience

Preface ix Book Features Clarifying Clips Video clips are available online to further clarify particularly challenging concepts when indicated by this icon Exercises and Conceptual Questions Assess your level of understanding as you progress through the book with the interactive online exercises and conceptual questions Important Equations Key physics equations are highlighted to facilitate efficient identification and review of critical concepts Animation and Image Library Additional images and animations are available online allowing for a deeper clinical understanding of ultrasound physics Common Misconceptions Common points of misconception are summarized to clarify areas of ultrasound physics that frequently give students the most difficulty Additional Online Resources In addition to Clarifying Clips Exercises and Images Animations complementary material includes additional chapters test taking strategies a quiz bank and CME access Chapter Summary At the end of each chapter key concepts are summarized providing a concise efficient method for chapter review Chapter Markers Quickly locate a chapter when flipping through the text with the vertical markers

x Ultrasound Physics Instrumentation Online Extras Accessing Online Content Supplemental online materials can be accessed through Pegasus Lectures using your unique access code found below 1 Visit www pegasuslectures com 6thEdExtras and enter your unique access code which can be found in the red box below 2 A My Pegasus account will be created for you or updated to include this book if you already have one 3 For future access to Online Extras log into your My Pegasus account at www pegasuslectures com top right corner of the home page 4 Open the Textbooks and Online Extras section to access the 6th Edition Extras and digital chapters 5 From the My Pegasus main page open the CME Center section to access continuing education credit exams and certificates If you have any questions or technical issues please email Pegasus Lectures Inc at info pegasuslectures com Access your supplemental online materials now Online Chapters To access supplemental online materials visit www pegasuslectures com 6thEdExtras Your unique access code for 6e Online Extras is 1234567890

NEW FOR INSTRUCTORS Custom Online Dashboard All new Instructor Dashboard allows for chapter by chapter monitoring of students progression through content View overall class progress or dive in deeper to track each student s completion of chapter content listed by page number Easy to read symbols indicate full completion solid green box partial completion half green half empty box or non completion empty box Activities are color coded for quick reference by category Each progress chart can be printed or saved for emailing at any stage of completion Updated PowerPoint Presentations Slides includes all new content and graphics from the new 6th edition including animations Quickly load each chapter in the Pegasus Presentation Viewer application and share the screen during class 16 9 widescreen format to accommodate most modern displays

Chapter Mathematics WH YD U ST WH OW DY AT s E TH To understand physics and not just memorize facts you must have a rudimentary understanding of mathematics IS Ultrasound registry exam physics questions require an understanding of the mathematical relationships of the variables in an equation IN LEVEL 1 BASIC ULTRASOUND PHYSICS Basic mathematical functions and relationships of variables within equations are introduced LEVEL 2 BOARD LEVEL Higher level math skills are presented including logarithms the binary system and concepts needed to understand Doppler hemodynamics T HIS LEA OB CH RN JE A R PTE Describe the value of mathematics in ultrasound ING IV CT Determine the basic relationship of variables within an equation ES Apply the concept of fractions percentages decimal notations reciprocals exponents the basic trigonometric functions of sine and cosine and logarithms Explain the difference between absolute and relative information and linear and non linear relationships 1

Chapter 2 Waves WH YD U ST WH OW DY AT s E Changing sound wave parameters can TH IS impact the diagnostic quality of the ultrasound image increase the potential risk of bioeffects LEVEL 1 BASIC ULTRASOUND PHYSICS We discuss basic wave properties and why understanding waves is important to anyone performing ultrasound developing the foundation for Level 2 LEVEL 2 BOARD LEVEL Many of the Level 1 concepts are reviewed but with specific reference to ultrasound applications creating a solid foundation for topics to be developed in later chapters IN TH HA IS C LEA O RN R PTE Recognize the four basic wave characteristics and parameters ING C BJE TIV Identify the clinical importance of controlling wave parameters ES Describe how wavelength affects resolution and reflection Define the impact of sound waves on acoustic intensity and bioeffects Relate and apply amplitude power intensity and decibels

Chapter Attenuation WH YD ST WH T HIS LEA O U OW DY AT s CH RN E TH The mechanisms of attenuation are what make ultrasound work or not work IS Identifying the mechanisms of attenuation is essential in understanding how and why system controls are used the source of artifacts and how advanced topics such as harmonic and contrast imaging are used LEVEL 1 BASIC ULTRASOUND PHYSICS Concepts of absorption reflection and refraction their relationship to the angle of incidence angle of reflection and angle of transmission and the impact on the ultrasound image are introduced LEVEL 2 BOARD LEVEL Level 1 concepts are expanded with a focus on the clinical impact and the resulting diagnostic ultrasound image LEVEL 3 ADVANCED TOPICS A deeper understanding of Level 2 concepts is developed including how to determine the maximum imaging depth for a specific frequency transducer IN AP R E T Describe how absorption reflection and refraction impact the level of attenuation in tissue the inferior structures and the resulting image ING C BJE E TIV Define Snell s Law and the clinical importance of understanding when refraction occurs S Apply ultrasound terminology to describe plaque echogenicity and surface characteristics Identify the importance of the critical angle Understand that absorption not only decreases signal strength but also serves as the foundation for understanding thermal bioeffects 3

Chapter Pulsed Wave Operation WH YD ST WH OW Y UD AT s E TH IS Pulsed wave sets the foundation for the timing of all ultrasound modalities except CW Doppler and determines the axial resolution IN The timing directly affects temporal resolution image generation techniques the risk of thermal bioeffects the maximum allowed transmit voltage and the maximum detectable Doppler velocities LEVEL 1 BASIC ULTRASOUND PHYSICS The various pulsed wave definitions and the relationships between these parameters are introduced LEVEL 2 BOARD LEVEL The PW parameters are associated to the practical application in ultrasound building the foundation for understanding the trade offs that exist in how images are produced TH IS LEA C HA RN JE OB R PTE ING CT S IVE Describe the advantages and disadvantages of pulsed and continuous wave operations List the various pulsed wave parameters Define the PW parameters that impact axial resolution Explain the relationship between imaging depth pulse repetition period and pulse repetition frequency Learn how to determine frame times and frame rates and understand the relation to temporal resolution 4

Chapter Transducers Piezoelectric WH YD ST WH U OW DY AT s E To create ultrasound images sound waves must be both transmitted and received TH IS IN A variety of transducers have been designed to meet the specific requirements of each type of imaging Until recently all ultrasound transducers were based on the piezoelectric effect LEVEL 1 BASIC ULTRASOUND PHYSICS The basics of transducers the piezoelectric effect and beam characteristics are discussed LEVEL 2 BOARD LEVEL Details the evolution of ultrasound transducers from single crystals and mechanical steering through complex 1D and 2D phased arrays with electronic focusing and steering to wireless transducers LEVEL 3 ADVANCED TOPICS Develops in greater detail the concept of the piezoelectric effect and compares the crystal structure of standard PZT ceramics with PMN PT single crystals T HIS LEA OB CH RN JE A R PTE List the beam parameters and how each affects ultrasound images Explain the piezoelectric effect ING IV CT ES Describe the evolution of transducers being able to explain why each advancement was made Identify the underlying principle of phasing used with phased array transducers Define the process by which sequential images are generated Draw and explain the basic block diagram of a transducer 5 Part I

Chapter Transducers CMUT WH YD ST WH U OW DY AT s E TH IS Capacitive Micromachined Ultrasonic Transducer CMUT technology is in the process of revolutionizing ultrasound CMUT is reducing cost increasing operating frequency ranges and creating new paradigms for ultrasound transducers and clinical applications LEVEL 1 BASIC ULTRASOUND PHYSICS The basics of CMUT theory are developed starting with the underlying principle of capacitance progressing through how a single capacitive cell produces sound and concluding with a basic block model of a CMUT cell LEVEL 2 BOARD LEVEL Continues the transducer evolution of the previous section showing how CMUT can be used as the foundation not only for 1D and 2D arrays but also for miniaturized array transducers that scan virtually the entire body IN TH HA IS C LEA RN JE OB R PTE Explain the concept of capacitance and how it is calculated ING CT S IVE Describe how varying the changing electric field of a capacitor can be used to create sound List the main components of a capacitive cell Explain how multiple cells can act as an element and how a group of these elements can constitute a transducer array List the advantages of CMUT relative to piezoelectric transducers 5 Part II

Chapter System Operation Fundamentals WH YD U ST WH TH IS LEA O OW DY AT s CH RN E TH By understanding the basic principles of image generation it is much easier to understand the fundamental imaging controls of an ultrasound system R ING T LEVEL 1 BASIC ULTRASOUND PHYSICS The basic functions of an ultrasound system are introduced leading to an explanation of how received signals are processed to generate images LEVEL 2 BOARD LEVEL Basic system controls and their effects on images are detailed in relation to how images are created optimized stored and displayed Level 3 ADVANCED TOPICS The concepts of video formats compression algorithms codecs and concepts related to human perception are discussed IN TE AP C BJE System operation connects the concepts learned to this point to explain the basics of how a system transmits sound waves captures reflections and generates an image IS S IVE List the core processing functions required to create an ultrasound image Explain the difference between true and apparent signal to noise Describe how beam former evolvement has advanced ultrasound Describe how signals are displayed and stored including the basics of monitors Identify the limitations of human perception 6 Part I

Chapter System Operation Advanced WH YD ST WH OW Y UD AT s Sequentially generated imaging is inherently temporally limited but increased processing power and speed allows for new image generation techniques E T S HI Studying advanced system operation reveals the trade offs between advanced system controls and optimal image quality LEVEL IN T HIS LEA O CH RN A New techniques allow for increased frame rates averaging improved resolution better signal to noise and reduction of artifacts R PTE 2 BOARD LEVEL Limitations of conventional sequential image generation are considered along with signal to noise and contrast A discussion of the theory of averaging follows including benefits and trade offs Temporal resolution is used to segue into the benefits of various image generation techniques Consideration of signal processing follows including improving image quality with speed of sound correction and adaptive processing and a discussion of advancements in 3D imaging extended field of view and CT MR PET fusion imaging The chapter concludes with a discussion regarding artificial intelligence and its application in ultrasound Explain the concept and benefits of averaging in imaging ING C BJE T S IVE List and describe the many new image generation techniques Identify the trade offs associated with various image generation techniques Describe the benefits of image processing techniques Define some of the benefits of 3D imaging Describe the application of fusion imaging Define the basic principles of AI and describe the use of AI in ultrasound 6 Part II

Chapter Doppler WH YD U ST WH OW DY AT s Spectral Doppler provides a means of quantitatively measuring velocity with respect to time E I TH Blood flow can be assessed from spectral waveform characteristics parameters calculated from the velocity measurements and from color flow visualization S Collectively Doppler provides information necessary to assess systemic hemodynamics and perfusion of organs IN LEVEL 1 BASIC ULTRASOUND PHYSICS General Doppler theory and fundamental principles are discussed LEVEL 2 BOARD LEVEL We examine how Doppler systems function including the difference between sequentially generated color and ultrafast Doppler We also discuss Doppler waveforms spectral Doppler and color Doppler T HIS LEA O CH RN A R PTE LEVEL ING C BJE T S IVE 3 ADVANCED TOPICS Detailed information is provided on angular errors wall filtering and associated effects on flow appreciation including vector flow V Flow imaging as a tool for assessing wall shear stress WSS Define the Doppler effect and Doppler equation Describe the parameters which affect the Doppler shift Identify processing steps in generating spectral and color Doppler Explain the system controls impacting Doppler signals Describe the difference between sequentially generated and ultrafast color Doppler 7

Chapter Artifacts WH YD U ST WH OW DY AT s E TH IS Understanding and recognizing artifacts is important so as to not make clinical errors based on artifactual appearance or lack of visualization IN LEVEL T HIS LEA OB CH RN JE A R PTE 2 BOARD LEVEL The underlying variables and assumptions of ultrasound artifacts are discussed Techniques to recognize the source and impact of artifacts are developed Identify that artifacts result from the violation of assumptions made in diagnostic ultrasound ING IV CT Just because you see something does not make it real and just because you do not see something does not mean that it does not exist List the underlying assumptions and the associated artifacts when these assumptions are violated ES Recognize the primary artifacts and understand the cause of the perceived artifact Describe how artifacts can be categorized according to appearance mechanism and or by modality 8

Chapter Bioeffects WH YD ST WH OW Y UD AT s Understanding bioeffects helps inform us of the potential risk of causing harm to a patient through the process of ultrasound scanning E T S HI Knowing the mechanisms of the risks of thermal and mechanical bioeffects and how to minimize them helps practitioners of sonography safeguard their patients Specialized transducers called hydrophones offer power and intensity measurements which provide additional information on bioeffects LEVEL 2 BOARD LEVEL Begins with a discussion of thermal and mechanical bioeffects including parameters and measurements of intensity and the limitations thereof Thermal and mechanical indices are introduced along with official AIUM guidelines and ALARA principle with warnings intended to reduce patient risk Level 3 ADVANCED TOPICS The mathematical approach to converting between various intensities is presented along with more detailed information about hydrophones IN TH HA IS C LEA O R PTE Identify the principal bioeffect mechanisms RN BJE List the parameters that increase the risk of mechanical and thermal bioeffects ING IV CT ES Describe the thermal TI and mechanical MI indices and the potential limitations to these models Recognize the official ultrasound safety statements describe prudent use and be able to paraphrase the ALARA principle Apply the absolute maximum recommended scan times for various TI values for specific types of scanning 9

Chapter Contrast and Harmonics WH YD U ST WH OW DY AT s Harmonic imaging has revolutionized ultrasound imaging by reducing near field clutter with improved penetration and lateral resolution E I TH Current approved uses of contrast imaging includes cardiac and liver specific applications with hopes for additional applications in the future T LEA O CH A 2 LEVEL IN HIS Contrast provides a very important tool for increasing signal strength and assessing tissue perfusion S R PTE LEVEL 3 BOARD LEVEL A discussion of the fundamentals of contrast imaging including the underlying physics principles Foundational as well as specific principles of harmonic imaging including benefits and drawbacks are introduced ADVANCED TOPICS In depth information on the applications of contrast and the specific modes of operation For harmonic imaging more advanced modes such as harmonic power Doppler and coded excitation are explained The section concludes with a discussion of some future anticipated applications Explain the fundamental principles of both harmonic and contrast imaging RN ING C BJE T S IVE Recognize the non linear aspects of harmonic signal generation Identify the non linear response to contrast agents Describe the advantages and disadvantages of harmonic imaging Define the different modes of contrast imaging Recognize the relationship between the bioeffect of cavitation and the cavitation of contrast agent 10

Chapter Quality Assurance WH YD ST WH OW Y UD AT s Quality assurance QA helps insure patient care is as accurate and effective as possible through lab accreditation personal certification equipment maintenance equipment testing statistical validation and more E T S HI Statistical validation mathematically compares patient results with a reference gold standard exam to ensure quality studies and interpretations LEVEL IN IS TH CH A QA programs make sure certain processes and procedures are in place to verify equipment used on patients is functioning correctly and personnel can optimally perform patient tests R PTE 2 BOARD LEVEL Begins by briefly discussing laboratory accreditation and personal certification followed by a discussion regarding transducer care equipment testing and the various phantoms and test objects which exist to facilitate this testing The chapter concludes with statistical validation including the meaning and significance of parameters such as sensitivity specificity negative positive predictive values and overall accuracy Describe the necessity for a quality program LEA RN JE OB Explain the basic role of various phantoms in equipment testing ING C E TIV Recognize the procedures used for testing various resolutions including lateral axial and contrast S Identify the underlying principle of statistical validation Apply the calculations for sensitivity specificity negative predictive and positive predictive values and the overall accuracy Define the true meaning and potential over interpretation of statistical calculations relative to the quality of the gold standard 11

Chapter Fluid Dynamics WH YD ST WH OW Y UD AT s Fluid dynamics is the foundation of for understanding the flow of blood or hemodynamics E T S HI The fluid dynamics equations are critical to hemodynamic assessment LEVEL IN TH IS LEA O CH RN BJE A R PTE 2 BOARD LEVEL Begins with a discussion of the underlying theory of fluid flow leading to intuitive derivations of the essential equations Foundational concepts of flow dynamics are discussed Equations for resistance volumetric flow continuity equation Poiseuille s Law and Bernoulli s equation are developed Finally laminar flow Reynolds number and turbulence are discussed Explain each of the foundational fluid dynamic concepts including capacitance resistance compliance and pressure gradients ING IV CT The equations from fluid dynamics are applied to the information obtained primarily in spectral Doppler to assess blood flow end organ perfusion in addition to cardiac and vascular disease ES Identify the equations for resistance flow and pressure gradients and apply the interrelationships Define the underlying principles of Bernoulli s equation Describe different types of fluid flow and what causes flow disturbances 12

Chapter Hemodynamics WH YD ST WH OW Y UD AT s Hemodynamics is the application of fluid dynamics to the flow of blood throughout the cardiovascular system E TH Hemodynamics allows for the assessment of the heart vasculature both arterial and venous and organ perfusion LEVEL IN IS TH LEA O CH A An ultrasound hemodynamic assessment is achieved primarily through spectral Doppler measurements but often combined with additional information acquired through 2D imaging color Doppler imaging and pressure measurements IS R PTE 2 BOARD LEVEL We begin by looking at pulsatile flow and the effects of complex resistive paths and the resulting energy loss This is followed by a discussion of the arterial and venous systems and the consequences of various disease states Next we look at how Doppler is utilized in the hemodynamic assessment including spectral characteristics velocity criteria pressure gradients volumetric flow approximations and Doppler indices We conclude with flow visualization Apply the concept of compliance and its importance in the cardiovascular system RN BJE Calculate the effects of series and parallel resistance networks ING IV CT ES Describe how the velocity decreases and increases as blood flows from the aorta through the periphery and back to the heart Explain the effects of hydrostatic pressure on venous return Define what occurs with a sub critical and critical stenosis Relate Doppler measurements to hemodynamic assessments 13

Chapter Patient Care and Sonographer Safety WH YD ST WH OW Y UD AT s As a sonographer keeping yourself and your patients safe is a high priority E T S HI LEA OB CH RN JE A It is important to make sure equipment is performing properly and to apply techniques for reducing the risk of work related musculoskeletal disorders LEVEL IN IS TH Several credentialing exams incorporate questions regarding patient care safety and communication R PTE 2 BOARD LEVEL This chapter begins by reiterating the safety aspects of patient care the need to observe standard precautions and the importance of verifying technical proficiency The second part of the chapter covers personal aspects of patient care including staffing issues patient communication and managing patient expectations The third part addresses sonographer safety primarily dealing with reducing work related MSK disorders Describe the correct methods to identify patients ING IV CT Explain the right for informed consent ES Identify that effective communication aids in patient compliance Describe how behavioral values will vary from patient to patient and between patients and sonographers List good ergonomic practices to reduce WRMD 14

Chapter Physics of Stress and Strain WH YD ST WH OW Y UD AT s The concepts of stress and strain are increasingly being utilized in ultrasound applications E TH IS Strain and speckle tracking can determine cardiac motion and muscle viability In elastography stress and strain can help differentiate normal from malignant tissue this is valuable for detecting breast liver and thyroid lesions and is growing in use in musculoskeletal MSK imaging 2 LEVEL IN T CH HIS A R PTE LEVEL 3 BOARD LEVEL The underlying concepts of stress and strain are examined including longitudinal shear and bulk The elasticity moduli Hooke s law and material properties are discussed Using spring models the concepts of wave propagation shear waves isotropy and anisotropy are developed Ultrasound applications and tissue differentiation techniques conclude this level ADVANCED TOPICS Simply stated equations are derived mathematically These equations relate the three different elasticity moduli bulk shear and Young s along with Poisson s ratio Define stress and strain as well as longitudinal shear and bulk forces LEA O RN Describe the concept of elasticity as it relates to Hooke s law ING C BJE T S IVE Specify equations relative to the bulk and shear wave moduli and recognize the relationships to Poisson s ratio Identify techniques for generating both strain and shear waves in elastography Explain why the Young s and shear moduli can better differentiate tissues Describe how an acoustic radiation force impulse ARFI can generate strain and shear waves 15

Chapter Elastography WH YD ST WH OW Y UD AT s Elastography creates images of tissue hardness which is an important indicator of tissue pathology and useful for cancer diagnosis and monitoring E T S HI Elastograms offer quantification of tumor mobility and interstitial fluid flow that promise to improve diagnosis of multiple other diseases LEVEL IN T HIS LEA O CH RN A Quantitative elastography is making it possible to diagnose additional pathology such as liver cirrhosis R PTE 2 BOARD LEVEL We begin the chapter with a brief review of key characteristics of strain and shear wave elastograms that are important for clinical diagnosis Important applications of elastography are discussed along with the elastographic features of breast cancers Reasons why elastography is not more widely used are presented along with approaches to reduce variability in quantification of tissue stiffness Finally variants of elastography that may be useful clinical tools in the future are reviewed Define the three main types of elastography in clinical use today ING C BJE T S IVE List the diseases for which elastography has been found to be a useful diagnostic tool Identify the elastographic features of breast cancer and the pitfalls one may encounter when performing elastography Describe steps that can be taken to reduce variability in elastography and collaborative efforts underway to improve quantification of tissue stiffness 16

Chapter Speckle Tracking and Cardiac Strain WH YD ST WH OW Y UD AT s The ability to distinguish normal heart muscle from damaged heart muscle is important for determining diagnosis and treatment of heart disease E T S HI LEA O CH RN A Provides non Doppler information about global and segmental myocardial deformation LEVEL IN IS TH Compared to other qualitative ultrasound technologies speckle tracking and cardiac strain is an objective measure for assessing myocardial contraction R PTE 3 ADVANCED TOPICS Begins with a discussion of the complex motion of the heart followed by an explanation of strain with numerical examples to develop a more intuitive understanding This is followed by a description of the various more conventional ultrasound modes and the information each yields Understanding the limitations of these modes we begin a discussion of how speckle tracking can be used to determine cardiac motion in 2D and 3D independent of angle The various applications of strain imaging and various displays are discussed Explain the definition for strain and how strain is calculated ING C BJE T S IVE List the various conventional ultrasound modalities used for assessing cardiac function and the associated benefits and limitations Define the basic concept of speckle tracking and describe how it can be used to track cardiac motion Identify the possible sources of error in speckle tracking Describe the clinical applications of strain imaging 17

Chapter Focused Ultrasound WH YD U ST WH OW DY AT s Focused ultrasound FUS has a wide range of currently utilized and potential medical applications including E TH IS Thermal heating for tumor and diseased tissue ablation LEVEL IN IS TH LEA O CH RN BJE A R PTE 3 ADVANCED TOPICS This chapter covers the following topics 1 Focused Ultrasound Overview 2 Physical Principles of Operation 3 Guidance Systems 4 Clinical Indications 5 Future Landscape Define the foundational concept of using focused ultrasound for therapeutic treatment ING IV CT Creating transient cellular membrane permeability for targeted drug delivery ES Relate the mechanisms used in focused ultrasound to the principal bioeffect mechanisms Describe how cavitation and thermal bioeffects can be used to treat diseased tissues Identify some of the applications of focused ultrasound 18

Chapter Musculoskeletal Ultrasound WH YD U ST WH OW DY AT s Musculoskeletal MSK ultrasound is a cost effective method by which to assess musculoskeletal structures pathology and injuries E TH IS The quality of the diagnosis is highly dependent on the skill of the sonographer LEVEL IN IS TH LEA O CH RN A R PTE ING C BJE T MSK ultrasound requires knowledge of system optimization for a variety of structures and recognition of normal and pathological tissue signatures and artifacts S IVE 2 BOARD LEVEL The chapter begins by discussing basic ultrasound system parameters such as transducers image formats and operating frequencies used in MSK ultrasound imaging This leads into a discussion of the physical principles of ultrasound and image optimization as relates to MSK ultrasound specifically Critical to successful MSK ultrasound is the ability to recognize the sonographic appearance of normal and pathological tissue characteristics Intrinsic to MSK imaging is the recognition of imaging artifacts especially anisotropy or angle dependent specular reflections which can lead to misdiagnosis when the imaging is not optimized and the artifact not recognized Identify ultrasound system parameters specific to MSK ultrasound Define the physical principles of MSK ultrasound and image optimization Describe the tissue imaging characteristics of MSK structures Identify normal and pathologic tissue signatures List artifacts commonly identified in MSK ultrasound 19

Image Optimization Based on Physics WH YD U ST WH OW DY AT s E TH IS In essence this chapter illustrates why understanding physics is helpful to people working in the ultrasound imaging field LEVEL IN IS TH LEA CH RN JE OB A R PTE C 2 BOARD LEVEL This chapter reviews techniques for improving ultrasound imaging in many challenging situations Specifically the chapter reviews optimization techniques for difficult to image patients superficial imaging spectral Doppler Color Doppler contrast enhanced imaging CEUS elastography ultrasound and optimizing frame rate and temporal resolution Identify how concepts taught in earlier chapters are applied in specific applications and situations ING E TIV Unlike other chapters which teach new concepts this chapter puts concepts taught in other chapters together to yield techniques for improving imaging situations which are often difficult Define why specific system settings are advantageous when significant penetration is required S List certain techniques to improve imaging in the near field Describe how optimization of Doppler differs from optimization for 2D imaging List the parameters that affect temporal resolution and understand how newer technologies are designed to significantly increase frame rate Chapter 20

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