Linköping Studies in Science and TechnologyThesis No. 1037

PERFORMANCE TESTING OF ULTRASOUNDDOPPLER EQUIPMENT

Andrew Walker

2003

Departments of Biomedical Engineering and Clinical Physiology, LinköpingUniversity, Linköping, Sweden and Department of Clinical Physiology and Centre for

Clinical Research, Central Hospital, Västerås, Sweden

Andrew Walker 2003

Printed by Unitryck, Linköpings universitet, Sweden, 2003

ISBN: 91-7373-728-3

ISSN: 0280-7971

III

ABSTRACT

Blood and tissue velocities are measured and analysed in cardiac, vascular and other

applications of diagnostic ultrasound. Errors in system performance might give invalid

measurements.

We developed two moving string test targets (“Doppler phantoms”) to characterise

ultrasound Doppler systems. These phantoms were initially used to measure such

variables as sample volume dimensions, location of the sample volume, and the

performance of the spectral analysis. Specific tests were done to detect errors in signal

processing causing time delays and inaccurate velocity estimation.

Even time delays as short as 30 ms in cardiac motion pattern may have clinical

relevance. These delays can be measured with echocardiography, by using techniques

such as flow and tissue Doppler and M-mode together with external signals (e.g., ECG

and phonocardiography). If one or more of these signals are delayed in relation to the

other signals (asynchronous), an incorrect definition of cardiac time intervals can

occur. To determine if this time delay in signal processing is a problem, we tested

three commercial ultrasound systems. We used a digital ECG simulator and a Doppler

string phantom to obtain test signals. We found time delays of up to 90 ms in one

system, whereas delays were mostly short in the other two systems. Further, the time

delays varied relative to system settings.

To determine the accuracy in velocity calibration, we tested the same three ultrasound

systems using the Doppler phantom to obtain test signals for flow and tissue pulsed

Doppler and for continuous wave Doppler. The ultrasound systems were tested with

settings and transducers commonly used in cardiac applications. In two systems the

observed errors were mostly close to zero, whereas one system systematically

overestimated velocity by an average of 4.6%. The detected errors can be considered

small in clinical applications but might be serious in certain research applications. It is

important to know the velocity error of the used ultrasound system and to judge it in

relation to the application in which it is used.

IV

LIST OF PAPERS

This thesis is based on the following papers, which are referred to in the text by their

Roman numerals:

I. Walker AR, Phillips DJ, Powers JE. Evaluating Doppler devices using a moving

string test target. J Clin Ultrasound 1982;10:25-30.

II. Walker A, Olsson E, Wranne B, Ringqvist I, Ask P. Time delays in ultrasound

systems can result in fallacious measurements. Ultrasound Med Biol 2002;28:259-263.

III. Walker A, Olsson E, Wranne B, Ringqvist I, Ask P. Accuracy of spectral Doppler

flow and tissue velocity measurements in ultrasound systems. Accepted for publication

in Ultrasound Med Biol, 2003.

The papers are reproduced with the permission of the publishers.

V

CONTENTS

Abstract ......................................................................................................................... III

List of Papers ................................................................................................................ IV

Contents ......................................................................................................................... V

1 Introduction ............................................................................................................. 6

1.1 Ultrasound physics and techniques...................................................................... 6

1.2 Clinical use of ultrasound and Doppler ............................................................... 9

1.3 Performance testing of ultrasound systems ....................................................... 10

2 Aims....................................................................................................................... 12

3 Summary of papers................................................................................................ 13

3.1 Moving string test target (Paper I)..................................................................... 13

3.2 Time delays (Paper II) ....................................................................................... 17

3.3 Spectral Doppler velocity (Paper III) ................................................................ 19

4 Discussion and Conclusions .................................................................................. 22

4.1 Moving string and other test methods ............................................................... 22

4.2 Time delays between different signals .............................................................. 24

4.3 Accuracy of velocity calibration........................................................................ 25

4.4 Conclusions........................................................................................................ 27

4.5 Future work........................................................................................................ 28

5 Populärvetenskaplig sammanfattning.................................................................... 30

6 Acknowledgements ............................................................................................... 32

7 References ............................................................................................................. 33

8 Appended papers ................................................................................................... 39

6

1 INTRODUCTION

1.1 Ultrasound physics and techniques

In medical diagnostic ultrasound frequencies in the range 2-10 MHz are commonly

used. Pulsed, or sometimes continuous, ultrasound is emitted into the body using a

piezoelectric transducer (Angelsen 2000; Holmer 1992). The ultrasound is reflected

and scattered in tissue and blood and part of the backscattered signal is detected by the

transducer in receiving mode. Displaying these echoes with intensity on the vertical

axis and depth on the horizontal axis of an oscilloscope is called A-mode. If the echoes

instead modulate the intensity of the display we get a B-mode display. Static two-

dimensional images could be acquired by manually sweeping the transducer over the

area of interest and keeping track of the transducer position and orientation. Two-

dimensional real-time images can be created by rapidly changing the direction of the

emitted ultrasound beam. This can be done either by a mechanical sector scanner or by

electronic steering of a multi-element transducer.

When ultrasound is reflected against a moving target of tissue or blood the ultrasound

frequency will change: this is known as the Doppler effect (Angelsen 2000; Holmer

1992; Jensen 1996; Nelson and Pretorius 1988). This shift in frequency, the Doppler

frequency fd, is proportional to the velocity of the moving target:

fd = (2 f0 v cosα ) / c (1)

where f0 is the transmitted frequency, v is the velocity of the moving target, α is the

angle between the movement vector and the transmitted ultrasound beam, and c is the

speed of sound in tissue. The Doppler frequency is mostly in the audible range (about

100 Hz to 10 kHz) and can be observed from a loudspeaker.

In reality the received Doppler signal will contain a range of simultaneous velocity

components leading to a complex spectral content. Under ideal uniform sampling

conditions the Doppler power spectrum should have the same shape as a velocity

7

distribution plot for the current flow or tissue motion. There are a number of factors

that distort the power spectra and which may limit the accuracy of the measured

velocity distribution. This is due to the blood flow or tissue motion condition, the

region of sensitivity and imperfections in the transducer and electronics and limitations

in the spectral analysis. Blood flow is different in different parts of a vessel or heart

chamber and can be turbulent. Also, the concentration of scatterers (blood and tissue

cells) is heterogeneous. The presence of highly reflective stationary or slowly moving

targets will also affect the spectral content (“clutter”). The region of sensitivity is

defined by the diameter of the ultrasound beam and, in the case of pulsed Doppler, the

axial dimension of the sample volume. The spectral content of the Doppler signal will

depend on where this region of sensitivity is placed in relation to the blood flow or

tissue motion. The scattering properties will also vary with the Doppler angle (α).

Further, the Doppler spectrum is widened due to intrinsic spectral broadening. In short,

this is because of the range of angles that are available as the target passes through the

ultrasound beam. In pulsed Doppler the wide signal bandwidth and the effect of

sampling may alter the shape of the power spectrum.

The zero-crossing detector and the more developed time interval histogram (TIH) were

widely used to display the spectral content of the Doppler signal. The TIH displays

well the centre frequency and width of the spectrum but gives no detailed information

about the shape of the spectrum. These techniques are not sufficient when several

velocity components are present simultaneously. A better estimate of the Doppler

spectrum is obtained from Fourier analysis. This requires a transformation of the

Doppler signal from the time to the frequency domain. This can be calculated using

the discrete Fourier transform (DFT). The DFT is efficiently implemented with

methods such as the Chirp-Z transform and the fast Fourier transform (FFT). Some

limitations of these Fourier transform analysers are:

1. The data segment length limits the spectral resolution.

2. The maximum frequency component that can be detected is half the sampling

frequency of the analyser.

8

3. The Fourier transform of a random signal is merely an estimate of the true

spectrum and has a large variance.

More detailed descriptions of the Doppler signal and the estimation of blood velocity

and the different methods of spectral analysis are given by Angelsen (2000), Hatle and

Angelsen (1993), and Jensen (1996).

The velocity is usually presented graphically as a spectrum with velocity on the

vertical axis and time on the horizontal axis, with the greyscale (intensity) indicating

the relative prevalence of the shifted signals. Motion toward the transducer is

presented above the zero line, whereas motion away from the transducer is displayed

below the zero line. Typical flow velocities in the cardiovascular system are 0.1 to 1.0

m/s, with velocities up to 6.0 m/s at constrictions. Cardiac tissue velocities are

commonly in the range 0.025 to 0.30 m/s.

In continuous wave Doppler ultrasound is emitted continuously from one transducer

(or one group of transducer elements) and another transducer (or group of elements)

detects the reflected signal. This technique is quite easy to implement and works fine

also for high velocities, but lacks the ability to indicate the depth from which the

velocity arises. Pulsed wave Doppler was developed to solve this problem (Baker

1970). Repeated pulses of ultrasound are emitted but the system only acts as a receiver

for a limited period of time or “window”. The time from emission to the beginning of

this period corresponds to the depth in tissue, whereas the length of the period

corresponds to the length of the area in tissue (sample volume) where motion is

interrogated. The width of the sample volume is determined by the ultrasound beam

profile.

Two-dimensional imaging can be combined with the pulsed and continuous wave

Doppler ("Duplex scanning") so that velocity can be measured at any point in the

image.

9

Colour Doppler is a further development of the pulsed Doppler, where coloured two-

dimensional images of blood flow are overlaid on the tissue images. Each line in the

colour two-dimensional image consists of a large number of sample volumes (range

cells). The mean velocity in each sample volume is calculated in the time domain

using autocorrelation technique. Velocity is usually presented using a colour scale,

where red represents motion toward the transducer and blue represents motion away

from the transducer. The brightness of the colour represents the magnitude of the

velocity.

1.2 Clinical use of ultrasound and Doppler

The diagnostic use of ultrasound developed around 1950, with the first heart

examinations performed in 1953 (Edler and Hertz 1954). In the beginning A-mode, M-

mode and static B-mode scanners were used, commercial real-time imagers emerged

around 1975. The clinical use of ultrasound Doppler began in the mid 1950s

(Satumura 1957). Pulsed and continuous wave ultrasound Doppler are now commonly

used in the non-invasive assessment of blood flow velocity in cardiac (Hatle and

Angelsen 1993) as well as other applications (Atkinson and Woodcock 1982). Pulsed

tissue Doppler is increasingly used to record regional myocardial tissue velocity (Isaaz

et al. 1989; Sutherland and Hatle 2000). Tissue velocity is lower than blood flow

velocity and measurement requires special signal processing.

The main use of Doppler is to measure velocity, but the velocity signals and

measurements are often used to derive other quantities. One example is the estimation

of the pressure drop across a flow obstruction:

∆p ≈ 4 v2 (2)

where the peak velocity v in m/s gives the pressure drop in mm Hg. This

approximation is derived from Bernoulli’s equation and is valid only for these units of

10

velocity and pressure and for the non-viscous stationary flow assumed with

Bernoulli’s equation. The number 4 is in this case not dimensionless.

In clinical practice of cardiac ultrasound it is also common to define and measure

different time intervals in the heart cycle. It is possible to compare local and global

cardiac events using combinations of signals such as flow and tissue Doppler, M-

mode, ECG and phonocardiography (Fukuda et al. 1998; Garcia-Fernandez et al. 1999;

Mishiro et al. 1999).

The above mentioned colour Doppler technique is often used to get an overview of

flow and motion, but is also used for quantification of flow areas, timing of flow

events in the heart, and is also the basis for certain techniques for studying tissue

motion.

1.3 Performance testing of ultrasound systems

The purpose of testing ultrasound equipment is to assure that required performance is

obtained at measurements. This is increasingly important in that quantification of

clinical measurements becomes more common. Entering quality systems such as

accreditation also puts demands on methods to assure optimal measurements.

Traditionally, methods for testing imaging performance have been developed and

applied (AIUM 1990; Brendel et al. 1976; Carson 1979; IEC 1986; Robinson and

Kossoff 1972). This work was often supported by various organisations, including the

American Institute for Ultrasound in Medicine (AIUM), the American Association of

Physicists in Medicine (AAPM), National Electrical Manufacturers Association

(NEMA), British Standards Institution (BSI) and the International Electrotechnical

Commission (IEC). The IEC and AIUM also initiated the development of standards

for measuring Doppler performance (AIUM 1993; IEC 1993; Reid et al. 1979). These

publications mention numerous test devices (e.g., the string and flow phantoms). A

more extensive description of measurable quantities in Doppler systems and of test

11

methods is given by Hoskins et al. (1994a). Reference is also given to international

standards. A more recent paper by Thijssen et al. (2002) describes methods for

measuring both imaging quality and Doppler performance. A string phantom was used

by these investigators to assess Doppler sensitivity, sample volume depth and

dimensions, velocity measurement, and channel separation.

Studies of Doppler performance, especially peak velocity estimation accuracy, have

been conducted in the past. Some tests of performance will be described in this thesis.

However, many other characteristics of ultrasound Doppler systems remain to be

evaluated. The rapid development of equipment including such new techniques as

harmonic imaging and tissue Doppler may require performance that was not

previously needed and puts new demands on performance testing.

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2 AIMS

The efforts to obtain more information from the ultrasound systems have led to very

complex systems. The operator has often little insight in the signal processing that

takes place in the instrument. However, meaningful interpretation of Doppler

measurements requires knowledge of system characteristics as well as the underlying

physics and physiology.

The overall aim in this study was to develop test methods to characterise Doppler

systems and to apply these test methods to a number of commercial cardiovascular

ultrasound systems.

This included the following efforts:

- to develop a moving string test target and methods to test ultrasound systems and

thereby ensure proper operation.

- to investigate time delays in the display of flow and tissue pulsed and continuous

Doppler, M-mode, phonocardiography, and auxiliary signals in relation to the ECG,

and to study to what extent the delays change with system settings in three common

ultrasound systems.

- to investigate the accuracy of the spectral Doppler velocity estimation in pulsed and

continuous wave Doppler, for both flow and tissue settings, in three common

ultrasound systems. This was done for the range of velocities encountered in cardiac

ultrasound.

13

3 SUMMARY OF PAPERS

3.1 Moving string test target (Paper I)

3.1.1 Method

A moving string test target was developed containing a DC-motor, pulleys, and a

string loop all mounted on a stable frame. The pulleys were cut with sharp "V"

grooves so that the string would move evenly. The string was made out of surgical silk

thread, which has a uniform diameter and was found to be a reasonable ultrasound

scatterer. The original test target had a fixed Doppler angle of 60 degrees. Another

target with a variable angle between 0 and 90 degrees was developed later. This unit

had two strings that could be operated at different independent velocities. The distance

between the strings was also adjustable. Figure 1 shows a later commercial version of

the string target, but the working principle is the same.

The target was placed in a water tank lined with absorbing rubber to minimise

undesirable acoustic reflections from the walls.

The transducer under test was placed in a holder with linear translators to provide

precision movement along three orthogonal axes. A linear potentiometer provided a

voltage proportional to the position of the transducer. As water is a weak attenuator,

gain settings of the ultrasound instrument were set to avoid saturation of amplifiers. A

piece of attenuating material could also be placed between the transducer and the

string.

14

Figure 1. Moving string test target and test set-up. The speed control makes the string move

at a constant velocity or any input velocity waveform. The transducer and the ultrasound

system detect the string motion.

Sample volume size was measured by moving the transducer and at the same time

detecting the Doppler signal amplitude. The Doppler amplitude signal was input to the

vertical axis and the voltage proportional to the position of the transducer to the

horizontal axis on an oscilloscope.

The spatial location of the sample volume was also checked. This was done by storing

a two-dimensional image of the string target and positioning the sample volume at

various sites that provided maximum Doppler output (Figure 2).

15

Figure 2. Multiple exposure photo. Arrows indicate sample volume position in B-mode

image for maximum Doppler signal. The string is moving horizontally at depth 1.5 cm (A)

and 4 cm (B).

If the location is correct, the bright dot defining the sample volume should fall exactly

on the line defining the string. This was done with the string at different depths.

The frequency content of the Doppler signal relates to the blood flow velocity. To

analyse the frequency content we used a FFT spectrum analyser. By changing the

string velocity, we could observe the corresponding change in frequency spectrum.

Using the dual string target, we could study the effect of simultaneous velocity

components with differing magnitudes and directions.

3.1.2 Results

A clinical pulsed Doppler instrument (Mark V Duplex scanner, ATL, Bellevue, WA,

USA) and a prototype annular array system were evaluated. The sample volume

dimensions were measured at a series of depths. In the ATL scanner at 3 cm depth, the

width was found to be 3.7 mm and the length 2 mm.

Figure 2 shows the sample volume location measurements made with the ATL

scanner. As can be seen, the sample volume in some locations did not coincide either

in angle or range with the string as defined by the two-dimensional image.

16

Frequency spectra were obtained under various conditions using the FFT spectrum

analyser. Using the annular array and constant string speed, we could show that

Doppler centre frequency changed linearly with the cosine of the Doppler angle as

expected. The ATL system was also tested for its response to two velocity components

within the sample volume. The ATL system presented Doppler frequency a TIH

(Lorch et al. 1977). Whereas the FFT analyser could clearly distinguish the two

velocity components, the TIH output fluctuated between the two frequencies and

displayed all frequencies in between (Figure 3C and 3D).

Figure 3. Separation of flow components

using FFT (left) and TIH (right).

A: One string moving away from

transducer.

B: One string moving toward transducer.

C: Two strings moving toward transducer

at different speeds.

D: Two strings moving in opposite

directions and at different speeds.

17

3.2 Time delays (Paper II)

3.2.1 Method

Three common ultrasound systems were tested in the text referred to as systems A, B,

and C. A similar test setup as shown in Figure 1 was used. In addition, an ECG signal

from a digital ECG simulator was input to the ECG, phonocardiography, and auxiliary

inputs of the tested ultrasound system and simultaneously to an external input on the

speed control of the moving string phantom. In this way the string will move and

generate Doppler signals in synchrony with the ECG, phonocardiogram, and auxiliary

signals. A display of these signals is shown in Figure 4.

Figure 4. The sector part of the image shows the string and the sample volume placed on it.

The lower part displays the pulsed Doppler (PW) together with ECG, auxiliary input (DCA),

and phonocardiogram (PHONO).

All three systems were tested with similar settings for pulsed and continuous wave

Doppler for flow, pulsed tissue Doppler, and M-mode. The sharp onset of the QRS

complex in the ECG signal was used as the time reference. Delay was defined as the

time difference between this point and the corresponding onset in the other signals.

From a pilot study, we suspected that some system settings could affect delays.

Therefore, these settings were varied in our tests: velocity scale, velocity scale

18

baseline, sweep speed and "edge" in system B. All measurements were done in three

ways:

1. Directly on the screen after the image had been frozen.

2. From the frozen image as recorded on videotape. This measurement was carried out

to verify that the video recording procedure itself did not introduce delays.

3. From the live image after it had been recorded on videotape. The tape was then

stopped, using the pause function of the videotape recorder. This measurement was

performed to see if there was a difference in delay between frozen and live displays.

The stability in time delay measurements was calculated to be ± 4 ms (± 1 SD).

3.2.2 Results

In general, the delays in systems B and C were small and did not vary with settings to

any great extent. In system B the auxiliary signal appeared 14 ms ahead of the ECG ;

in system C the phonocardiography signal was displayed 13 ms ahead of the ECG. In

system B a change in "edge" setting from +1 to 0 increased the delay in Doppler

signals with 11-15 ms. In system A we found large time delays in all Doppler modes,

where the delays varied with velocity scale settings. Delays up to 90 ms were found.

An example from tissue pulsed Doppler is shown in Figure 5.

Tissue pulsed Doppler

-20

0

20

40

60

80

100

0.0 0.5 1.0 1.5 2.0

Velocity scale settings ±[m/s]

Dela

y [m

s]

frozenvideo livevideo frozen

Figure 5. Time delays in tissue pulsed

Doppler as a function of velocity scale in

system A (± in the velocity scale denotes

that the baseline was put centrally in the

image and that both positive and negative

velocities were displayed).

19

In system A there was also a difference in delay between frozen and live displays. The

delays for all Doppler modes were about 20 ms longer in live than in frozen displays.

For M-mode, the corresponding difference was about 15 ms.

3.3 Spectral Doppler velocity (Paper III)

3.3.1 Method

The same three ultrasound systems as in paper II were evaluated and are in the same

way called systems A, B, and C. The test set-up is the same as shown in Figure 1. In

this study the velocity of the string had to be known accurately. The string phantom

has a tachometer signal output from the motor, that provides readout of string velocity

on the speed control unit. This readout was carefully calibrated using a digital

tachometer to measure speed of rotation and a slide ruler to measure the diameter of

the string drive pulley.

Doppler frequency is dependent on the speed of sound in the medium where it is

generated. Because our measurements were done in water (~1480 m/s) and the

ultrasound systems are calibrated for soft tissue (~1540 m/s), we corrected for this by

multiplying the velocity values with a correction factor (Goldstein 1991b). We used an

angle of 45 degrees between the ultrasound beam and the string motion. A special set-

up procedure ensured a correct angle, ± 1o (Goldstein 1991a). The total accuracy of the

test system was estimated to be better than ± 1.8% at velocities at and above 0.200 m/s

and better than ± 4.9% at lower velocities.

The ultrasound systems were set at similar clinical settings. The string speed was

varied in the range 0.250 to 4.00 m/s for pulsed and continuous Doppler for flow and

in the range 0.025 to 0.500 m/s for pulsed tissue Doppler. The velocity scales of the

ultrasound systems were adjusted to comply with the present string velocity. A typical

spectral Doppler signal is shown in Figure 6. The spectral image was frozen and

measurements were done directly on the screen using the ultrasound system callipers.

The true string velocity corresponds to the mean Doppler velocity, which was

20

measured at the estimated centre of the spectrum (Lange and Loupas 1996).

Measurements were repeated three times, with the results presented as mean values.

Figure 6. The sector part of the image shows the string and the sample volume placed on it.

The lower part displays the Doppler spectrum, with string velocity measured in two points in

the centre.

3.3.2 Results

The measured errors for the different systems and tested modes are shown in Figure 7.

In general, the mean errors were below 5% for all systems and tested modes, but errors

of up to 8.3 % were detected at certain velocities. In systems B and C the errors were

mostly near or spread around zero. System A systematically overestimated velocity by

an average of 4.6%.

21

Mean error and confidence limits (95%)

-2.0

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

P C T P C T P C T

System(A,B,C) and mode

Erro

r [%

]

Mode:P = pulsedC = continuousT = tissue

System A System B System C

Figure 7. Mean value and confidence limits (95%) for the percentage difference between

measured [mean of three measurements] and true velocity in ultrasound systems A, B and C.

22

4 DISCUSSION AND CONCLUSIONS

4.1 Moving string and other test methods

The string phantom was developed and used to study Doppler ultrasound system

properties (e.g., sample volume size and localisation) and to illustrate how frequency

spectra were influenced by string velocity, Doppler angle, and multiple velocity

components within the sample volume.

A string was chosen as test target in the phantom design in that it makes it reasonably

easy to implement a test phantom that can be used to evaluate and demonstrate several

different properties of the tested ultrasound system. String phantoms with similar

design as the phantom described in Paper I have been used by numerous investigators

(Cathignol et al. 1994; Daigle et al. 1990; Eicke et al. 1993; Eicke et al. 1995;

Goldstein 1991a; Hames et al. 1991; Hoskins 1994a; Hoskins 1996; Lange and Loupas

1996; Phillips et al.1990; Russell et al.1993; Thijssen et al. 2002; Wolstenhulme et al.

1997). It is rather easy to calibrate accurately for velocity, the string has a small

diameter so that the sample volume size and position can be studied and it is also

suitable for testing several variables derived from the velocity signal. It is relatively

easy to steer so that it is possible to produce a predefined waveform with high

acceleration and well-defined timing. The string phantom is also recommended in

standards (AIUM 1993; IEC 1993) and reports (Hoskins et al. 1994a).

One disadvantage with string phantoms is that the obtained signal is stronger than that

at in vivo measurements. Thus, the sensitivity of the equipment has to be turned down.

A proper choice of string filament can reduce the backscatter to a level more

resembling the in vivo situation. It should also be noted that some string filaments,

depending on the structure of the string, have varying backscatter characteristics in

different directions (i.e. depending on the Doppler angle) (Cathignol et al. 1994;

Hoskins 1994b). Further, the moving string only simulates one velocity at a certain

time while physiological flow contains a range of velocities. String phantoms with two

23

strings moving at different velocities have been designed (Lange and Loupas 1996;

Walker et al.1982). The test procedure could be improved to provide signals more

close to physiological conditions. For example, tissue equivalent material could be

placed between the transducer and the string. A highly reflective target placed near the

string can simulate the strong reflections from vessel walls.

Doppler flow phantoms circulating a blood mimicking fluid in tubing have some

advantages, one being a more physiological measurement situation (Boote and

Zagzebski 1988; Groth et al. 1995; Hoskins et al 1994a; IEC 1986; McDicken 1986;

Thijssen et al. 2002). This makes flow phantoms suitable for studying volume flow,

velocity profiles, and three-dimensional flow. On the other hand, they are not very

suitable for testing velocity accuracy of instruments because they are only calibrated

for mean velocity and the velocity varies across the tube diameter depending on the

flow profile. They are also not well suited for assessing sample volume location and

size or for studying timing problems in that a time-controlled signal might be harder to

obtain.

Other types of phantom have been designed utilising a rotating disk (Nelson and

Pretorius 1990), a rotating torus (Stewart 1999) or a rotating belt (Rickey et al. 1992).

The rotating disk is well suited for velocity calibration but not intended for measuring

sample volume dimensions. The rotating torus is primarily intended for assessing

colour Doppler accuracy and gives a rather realistic signal with a low velocity

gradient. It is, however, large and unwieldy and it is difficult to eliminate the air

bubbles. The rotating belt is also useful for colour Doppler velocity evaluation, but it is

not suitable for studying sample volume dimensions. Other suggested and used

methods, primarily for sensitivity measurements, include a vibrating plate, an

oscillating small ball, and a moving piston (Hoskins et al. 1994a; IEC 1993). The

oscillating ball could also be used for determining the sample volume dimensions. A

different way of testing the equipment is to inject calibrated signals into the system

under test. This can be done electronically or acoustically. Electronic injection (Reuter

and Trier 1983) offers the possibility to simulate almost any desired signal but does

24

not test the transmitter, transducer or beamformer circuits. It also requires a detailed

knowledge of the input of the tested system. The acoustical method seems more

promising but is relatively new and needs further evaluation. Further, such systems for

routine use are not widely available.

4.2 Time delays between different signals

Three commercial ultrasound systems were tested for time delays in the spectral

display of Doppler signals in relation to ECG, phonocardiographic, and auxiliary

signals.

To measure short time delays a signal with a stable and rapid change of amplitude is

needed. A simulated ECG signal was used, both as the time reference (ECG input) and

as the input to the string phantom to generate Doppler signals. Other step-like signals

could have been used. A potential error is the delay that is due to inertia in the motor-

string system. This delay was constantly monitored and compensated for. Another

potential error source concerns the establishment of the reference point for time

measurements in the Doppler spectrum (as defined in section 3.2.1). To reduce the

uncertainty of this reference point we repeated measurements on three consecutive

simulated heartbeats.

Our ambition was to find all settings that could affect delays. Even though we

investigated many different settings, modern ultrasound systems have so many

combinations of settings that some settings leading to delays may have eluded us.

In clinical use different signals (e.g., ECG and Doppler velocity) are compared when

defining and measuring regional and global cardiac events and time intervals. It has

also been shown that local time delays of cardiac events as short as 30 ms may be

important when diagnosing ischemic heart disease (Garcia-Fernandez et al. 1999). In

two systems the delays were small (less than15 ms). In the third system we found

considerable time delays (up to 90 ms) which could have clinical implications. The

25

delays varied with system settings (specially the velocity scale) and were dissimilar in

live and frozen displays. We have not found the problem of time delays in Doppler

ultrasound signals previously described in the literature.

It is our belief that the technical problem of time delays in different signals in

ultrasound systems should attract more attention from manufacturers and medical

investigators. The manufacturers should ensure that there are no such significant

delays in their equipment.

4.3 Accuracy of velocity calibration

System A consistently overestimated velocity by an average of 4.6%. The other two

tested systems (B and C) showed mostly small errors in velocity calibration for

velocities above 0.25 m/s; furthermore, the average velocity errors in all the

investigated velocity ranges were below 2.2%. There was no systematic difference

between the different Doppler modes in any of the systems. At velocities equal to and

below 0.25 m/s, larger errors were found; however, these errors may partly be due to

inaccuracies in the performance of the Doppler phantom at the lowest velocities.

The errors reported in this study are relatively low compared with those previously

reported in the literature (Table 1). There may be several reasons for this result. In

earlier studies peak velocity was measured, whereas we measured mean velocity.

Because of spectral broadening, measurement of peak velocity will yield an

overestimation (Newhouse et al. 1980). It has also been shown that the type (structure)

of filament used in string phantoms in combination with the Doppler angle directly

affects the intrinsic spectral broadening (Cathignol et al. 1994; Hoskins 1994b).

Because the aim of this study was to examine the velocity calibration of the US

systems, and not the method of velocity estimation per se, the spectral broadening is of

less interest.

26

Table 1. Errors in velocity reported in earlier studies.

Reference Phantom Transducer Velocity range

(cm/s)

Angle

(°)

Error

(%)

Daigle, 1990 String L 93 50 -3 - 30

String S 93 50 6 - 11

String L 93 70 3 - 61

String S 93 70 8 - 16

Groth, 1995 Flow L 6 - 25 50 7 - 30

Hoskins, 1996 String L, CL, PA 50 - 250 40 - 70 -4 - 47

Kimme Smith, 1990 Flow L, S, PA, M 25 - 75 50 - 60 -25 - 60

Flow S 25 - 75 80 35 - 100

Rickey, 1992 Belt D, L 0 - 80 70 -10 - 12 (mean)

Present study, 2003 String S 2.5 - 400 45 -4.5 - 8.0

L= linear, S= sector, CL= curved-linear, PA= "phased array", M= "mechanical", D= "duplex"

A stable, accurate test velocity source is needed for the measurement of ultrasound

system velocity accuracy. It should be easy to calibrate, use, and cover a sufficient

velocity range (0.025 - 4 m/s). The string phantom is calibrated using a slide calliper to

measure the diameter of the drive pulley and a digital tachometer to measure the speed

of rotation. The total uncertainty of the test system consists of uncertainties in the

diameter of the drive pulley, speed of rotation, resolution (digits) in phantom read-out,

Doppler angle, and speed of sound (ultrasound velocity) in water. The total relative

uncertainty will vary with velocity and was ± 1.8% for the velocity range 0.200 – 4.00

m/s and in the range ± 3.0 to ± 4.9% for the lowest velocities (0.025 - 0.100 m/s). The

main sources of uncertainty are the Doppler angle at high velocities and the last digit

of the Doppler phantom display at lower velocities.

We have not found any specified demands on velocity accuracy in the literature.

Varying clinical and scientific measurements of velocity may demand different levels

of measurement accuracy. If no such requirements are stated in the literature, the

investigator should define what accuracy is needed and assure that this is met in all

27

measurements. However, it is mostly reasonable to accept an uncertainty of ± 5% in a

clinical routine investigation. In research or other special investigations the needed

accuracy might be higher.

In systems B and C the average errors were close to zero and therefore not considered

of clinical importance. Even the overestimation by an average 4.6 % in system A

might not be of importance in a single measurement. However, when comparing

measurements done at different occasions with different ultrasound systems, the

problem might become more significant. Moreover, processing of velocity data may

increase the uncertainty. An example is when estimating pressure drop using the

modified Bernoulli equation where the velocity is squared. In this case the percentage

of uncertainty will double.

4.4 Conclusions

The purpose of the presented test methods and investigations has been to improve the

understanding of Doppler systems and to characterise them so that it is possible to

separate instrumentation effects from measures of physiological variables.

It has been shown that a moving string test target is useful in providing information on

Doppler ultrasound system performance. The technique is easy to implement, can help

the user to reach a better understanding of ultrasound system function and controls,

and can ensure that the system is working properly.

Investigations using the string target have shown that serious time delays can be

present in the display of Doppler and M-mode signals in relation to ECG and

phonocardiography. These delays were affected by system settings and were dissimilar

in frozen and live displays. In the present study delays as long as 90 ms were found in

one system. These delays can lead to serious errors when defining and measuring time

intervals of the heart cycle. This type of delay was rather unexpected and emphasises

28

the importance of a critical attitude to acquired data and the importance of methods for

objective testing of ultrasound systems.

We have shown that the velocity calibration was quite accurate in two common

ultrasound systems, whereas a third common system consistently overestimated

velocity by about 5%. This was found both in the higher velocity ranges used in

(cardiac) blood flow measurements and in the lower ranges used in (myocardial) tissue

velocity measurements. The errors found may be acceptable in clinical measurements

but could be unacceptable in certain research areas.

4.5 Future work

There are many tests that could be done on Doppler ultrasound equipment

performance. Some will be discussed here.

The tests of time delays and velocity accuracy described in this thesis should be

extended to other ultrasound systems and to other transducers than sector transducers.

Further, measurement of velocity accuracy and linearity within each measurement

range should be investigated.

Time delays and velocity accuracy were only studied in spectral Doppler but could be

extended to (two-dimensional) colour Doppler imaging for both flow and tissue

movement.

Two-dimensional colour Doppler is often considered a real-time technique. In reality,

the acquisition time can be up to 200 ms per image. Using an external ECG delay, it

has been shown (with the string phantom) that it is possible to time correct flow

velocity images (obtained by sequential sector scanning) for this error (Eidenvall et al.

1992). In modern high framerate ultrasound equipment the image formation is more

complex and potential timing errors should be investigated. The Doppler string

phantom can be used for this test as it can simulate rapidly changing blood flow

29

velocity. An improvement of the string phantom so that the Doppler angle is constant

across the (sector) image would be desirable.

Spatial, velocity, and temporal resolution of both spectral and colour Doppler could be

tested using the string phantom.

Modern ultrasound systems include several functions for calculating (derived)

variables from the primary velocity, time, and spatial data. The string phantom could

be useful in testing the accuracy of these calculations by simulating predefined

velocity waveforms.

The development of new techniques, such as tissue velocity imaging, harmonic

imaging, and the use of contrast also require evaluation of performance. These new

techniques might require that new test methods be developed.

Measurement and display of blood flow characteristics are the primary functions of

Doppler instruments, where velocity and time measurements are the primary

quantitative data. Therefore, manufacturers should specify the accuracy (including

eventual delays) and resolution of these variables, including reference to the test

methods used (when establishing these data). Further, professional and scientific

societies in the field of diagnostic ultrasound should include demands on ultrasound

system accuracy in their guidelines, recommendations, and standards. Commercial test

phantoms, including test protocols, should be made available so that performance can

be verified in a non-research environment.

30

5 POPULÄRVETENSKAPLIG SAMMANFATTNING

Vid hjärt- och kärlundersökningar med ultraljud mäter och analyserar man bl a

blodflödet och vävnadens rörelse. Mätfel i den använda mätutrustningen kan eventuellt

leda till felaktig diagnos. Det är viktigt att kalibrera och kontrollera sin utrustning med

jämna mellanrum, för att säkerställa sina mätresultat.

Vi utvecklade därför en testutrustning (“Moving string test target”, "Doppler-fantom")

för kalibrering av ultraljudutrustning, som består av en motor som driver en tunn tråd

och som i sin tur på ett kontrollerat sätt simulerar rörelsen hos blod eller vävnad. En

sådan testutrustning kan användas för att testa flera olika egenskaper hos

ultraljudutrustningen. I dessa arbeten har vi främst studerat tidsfördröjningar av

signaler och noggrannheten i hastighetsmätningar, och också visat andra

användningsmöjligheter ( t ex mätområdets (”sample-volymens”) utbredning och läge,

jämförelse av olika beräkningsmetoder för flödeshastighet, riktningskänslighet samt

inverkan av vinkeln mellan rörelseriktning och ultraljudstråle).

Tidsfördröjningar

Vid hjärtundersökningar med ultraljud (ekokardiografi) är det bl a viktigt att studera

och mäta tidsintervall och tidsrelationer mellan olika händelser i hjärtcykeln. Dessa

tidsrelationer kan mätas med tekniker som flödes- och vävnads-Doppler och M-mode,

tillsammans med externa signaler som EKG och fonokardiografi (hjärtljud). Om en

eller flera av dessa signaler visas fördröjda i förhållande till de övriga (ej synkrona),

kan vi få felaktiga mätvärden. För att utröna om detta var ett problem, undersökte vi

tre vanliga ultraljudutrustningar. Vi lät en digital EKG-simulator generera samtliga

testsignaler genom att den även styrde Doppler-fantomen. Vi fann fördröjningar upp

till 90 ms i en apparat medan de andra två apparaterna hade relativt små fördröjningar.

Fördröjningarna i den första apparaten förändrades vid olika apparatinställningar, t ex

hastighetsskala, rörlig respektive fryst bild samt direkt bild respektive videoinspelning.

Eftersom man visat att förändringar i hjärtats rörelsemönster, som är kortare än 30 ms,

kan ha klinisk betydelse så är det funna felet allvarligt.

31

Hastighet

Vi undersökte även om de tre utrustningar var riktigt kalibrerade för flödes- och

rörelsehastighet, mätt med pulsad och kontinuerlig Doppler. Samma testutrustning

användes, men nu var den noggrant kalibrerad i aktuellt hastighetsintervall (0.025 –

4.00 m/s). Vi fann bara små fel (medelfel ≤ 2,2 %) i två av apparaterna, medan en

apparat visade systematiskt cirka 4,6 % för höga värden. Vid en normal, klinisk

undersökning har de funna felen knappast någon större betydelse, men kan ha det i

vissa vetenskapliga studier. Det är alltså viktigt att känna till hastighetsfelet i en viss

apparat, så att man kan bedöma dess betydelse i den aktuella applikationen.

Våra undersökningar visar att det viktigt att ha en kritisk attityd till sina mätresultat.

Det innebär att fabrikant och användare måste ha metoder för att kontrollera sin

ultraljudutrustning.

32

6 ACKNOWLEDGEMENTS

I wish to thank all those who have helped and supported me and especially:

Per Ask, professor and my tutor, for making this work possible, for good supervision,

and for always being available when needed.

Ivar Ringqvist, professor and co-tutor, for introducing and inspiring me to the field of

scientific research during more than 25 years and for his constructive help with the

preparation of manuscripts.

Bengt Wranne, professor and co-tutor, for his monumental help and interest in this

work and for his swift response to new versions of manuscripts.

Eva Olsson, MD and co-author, for her patience and devotion during hundreds of

measurements on ultrasound systems.

David Phillips, PhD (posthumously) and Jeffry Powers, PhD, co-authors (in Paper I),

formerly at the Department of Surgery and the Center for Bioengineering, University

of Washington, Seattle, for their inspiration during the first steps toward this thesis.

The Department of Clinical Physiology, Central Hospital, Västerås, my employer, for

giving me the opportunity to do this research.

The Centre for Clinical Research, Central Hospital, Västerås, especially for help with

practical and statistical matters.

And not the least my family, Marie-Louise, Lotta and Camilla, for their patience and

for accepting strange working hours.

This work was supported by grants from the County of Västmanland, Sweden, from the

Swedish Research Council, from the Swedish Heart-Lung Foundation, and from the SSF

program Cortech.

33

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