6.

4 Display modes
Once the diagnostic information has been acquired and electronically processed, it has
to be displayed for viewing and recording. Different methods are used to display the
information acquired from ultrasound examinations. The commonly used modes are
outlined in this section.

6.4.1 The amplitude mode (A-mode)

In the amplitude mode, the signals from returning echoes are displayed in the form of
spikes on a cathode ray oscilloscope (eRO), traced along a time base (see Fig 6.3). On
one axis (vertical axis in Fig 6.3) the amplitude of the signal (magnitude of the voltage
pulse) is displayed, and on the other axis (horizontal), the position of the signal on a time
scale is represented.

The amplitude of a spike is a relative measure of echo size. Because of the

relationship between the distance of a reflector and the time of echo reception, the
position of a spike along the time base is a measure of the distance of the associated
reflecting boundary from the transducer.
 I
( Refi\Ors /
GENERATION ... Ultrasound
T
~
~~
OF SCAN LINE beam path
DATA I
I I I I
I I I I I
I I I
I I I I I
Signal size r--
I I I I I
I I I I I
I
! ! I I

DISPLAY
T T
I
I
:I ,I
I
I

-
0
1
0
liy 0 0
Tine base

Fig 6.3 Display of infomatioo in A-IWde: Each sp:ike corresponds to

a reflecting interface along the scan line

The A-mode suffers from the limitation of displaying only l-D information,
representing the echoes lying along the beam path. The information does not constitute
an image. Additionally, the display has the disadvantage of taking up a lot of space on
the eRO in relation to the amount of information that it provides.

6.4.2 The brightness mode (B-mode)

In the brightness mode, signals from returning echoes are displayed as dots of varying
intensities. The spike of the A-mode is replaced by a small dot which occupies much less
space on the eRO. The intensity of a dot (the brightness) is a relative measure of
echo size, with large echoes appearing as very bright dots, while at the other extreme
non-reflectors appear totally dark. As in A-mode, the signals are presented along a time
base on the eRO. The position of a dot along the time base is a measure of the
distance of the associated reflector from the transducer. For any given position of the
beam direction (scan line), a line of dots is displayed on the eRO, corresponding to the 1-
D information of reflectors lying along the scan line. When the beam is swept across a
selected section of the subject (the process of scanning), different dot lines are created for
each scan line. These different dot lines are displayed at different positions on the eRO,
displaced laterally from one another, in relation to their corresponding beam positions.
The combined information from different scan lines provides a 2-D image of the
cross-section through which the beam sweeps. One dimension represents depth
information, while the other represents lateral variations in the direction of beam sweep.
Fig 6.4 illustrates the relationship between the positions of scan lines and the display of
dots on the CRO to build the 2-D image.

Beam sweep

Reflectors

GENERATICN Ultrasound
OF SCAN LINE beam path
DATA

Shift of
scan line

:I ~
I
I
I
I I
I
I
I
I
I
DISPIAY I I I I j

I I I I
I I I I I

•
I
.
I ! I
• • •
I
1 - - - - - + T:ime base
o 0 0 0

Fig 6.4 Display of information in B-mode: Each dot corresponds to

a reflecting interface along the scan line

The speed and the rate at which the ultrasound beam is swept across the subject will
determine whether a static or a real-time image will be generated (see Chapter 7).

6.4.3 The motion mode (M-mode)

The motion mode is used to generate an electronic trace of a moving object lying along
the path of the ultrasound beam. The transducer is placed in one fixed position in relation
to the moving structure. Returning echoes are displayed in the form of dots of varying
intensity along a time base as in B-mode. Dots for stationary reflectors will remain in the
same positions along the time base, but dots for reflectors which move in the direction of
the scan line will change their positions along the time base, because their distances from
the transducer will be changing with time. To capture the time variation of moving
structures graphically, dot lines obtained at different moments are recorded at different
lateral positions on the eRO. This is achieved by applying on the eRO an electronic
sweep of the dot lines perpendicularly to the direction of the time base (see Fig 6.5). A
time trace of the dot lines along the beam path is thus obtained. It should be noted that
the sweep of dot lines on the eRO is achieved by purely electronic means.

(U' ,

Electronic
~
S\\eep of "
dot lines
..
••
••
..
••
Tine base

0 0 0 0

Fig 6.5 M-rno<ie:Traces of dot lines for IIX>ving structure M and

stationary structure S.

Results: Stationery structures whose dots do not shift positions will trace straight
lines perpendicularly to the time base, while moving structures will trace zig-zag or
sinusoidal patterns.

The M-mode provides I-D information along the beam path. It should be noted that
for a moving structure to be detected, it must lie along the ultrasound beam path. The M-
mode is particularly useful in examining cardiac motion.
 6.4.4 Real-time mode
Real-time imaging is rapid B-mode scanning to generate images of a selected cross-
section within the subject repetitively at a rate high enough to create the motion picture
impression. A rapid succession of images of the same plane are generated and viewed as
they are acquired. Although in reality each image in the series represents an independent
static image, the effect of rapid acquisition and viewing at rates exceeding about 25
image frames per second creates the impression of continuity in time. This impression
arises due to limitations in human perception. We are unable to distinguish in time
between events occurring at intervals shorter than about 40 milliseconds - they appear to
us to occur "at the same time".

The evolution of ultrasonic imaging into the realm of real-time was a milestone in
diagnostic imaging. It is now considered a necessity in the practice of clinical ultrasound.
The design of transducers capable of achieving the high framing rates required for real-
time imaging is discussed in Chapter 7.

6.4.5 The Doppler mode

Before discussing the Doppler mode as a tool in clinical ultrasound, it is appropriate to
introduce the Doppler phenomenon in general. The Doppler effect is observed in the
behaviour of sound as well as light. In acoustics, it is associated with relative motion
between the source of sound and the receiver, resulting in an apparent difference in
frequency between that emitted by the source and that perceived by the receiver. An
approaching sound source is perceived to be emitting sound at a higher frequency than it
actually is, while a receding source appears to emit at a lower frequency. This situation
arises because the wave fronts in the pressure wave of an approaching source are pushed
closer together, while the wave fronts in a receding source are pulled further apart (see
Fig 6.6).
 R R

(a) stationary source,S (b) Approaching

source
(c) Receding
source

Fig 6.6 IPppler effect: Wavefronts are ccmpressed for approaching source,
and deccmpressed for receding source, as perceived by the receiver, R.

The apparent difference in frequency is called the Doppler shift. For a stationary
source, the wave fronts are neither compressed nor stretched, hence no shift of frequency
is observed. The Doppler shift can be measured and used to:

detect motion
determine the direction of motion
determine the velocity of a moving structure.

In clinical ultrasound, the Doppler mode is used in studies of blood flow and cardiac
movements. When a beam of ultrasound emitted by a transducer at constant frequency
interacts with a moving acoustic boundary, the boundary will, through the echoes it sends
back to the transducer, act as a secondary source of ultrasound for the transducer
(effectively, the reflecting boundary becomes the source, while the transducer serves as
the observer). Because the boundary is moving, the transducer will detect the echoes
with a Doppler shift in frequency, being of higher frequency if the interface is
approaching, or of lower frequency if the interface is moving away.

Both continuous wave (CW) and pulsed wave (PW) techniques are used in Doppler
ultrasound. In CW Doppler units, the transducer assembly has separate crystal elements
for producing the ultrasound beam and for detecting the echoes. One crystal
 continuously emits and the other continuously receives, it is not possible for one and the
same crystal to transmit and detect ultrasound at the same time. By comparing the
frequency of the echoes with that of the transmitted beam, it is possible to study motion
(see Fig 6.7). The shift of frequency is related to the velocity of the moving reflector, and
to the direction of motion. The greater the Doppler shift, the higher the velocity of
the moving structure, and a higher detected frequency implies relative motion
towards the transducer, while a lower detected frequency implies a receding
reflector.

Transni tting Blood flow

crystal

-
)
Velocity component
of blood

Receiving
crystal

Fig 6.7 Doppler shift in flow studies

The distance of a moving structure from the transducer cannot be determined by CW

ultrasound, since the go-return time for the ultrasound beam will not be known.
Determination of range requires the use of pulsed beams. More sophisticated Doppler
shift equipment utilizes PW ultrasound in conjunction with B-mode scanning to detect
movement and determine range, and to produce images of regions of movement.

6.5 Ultrasound equipment and display modes

The general purpose equipment for diagnostic ultrasound will typically be a B-mode
scanner capable of generating real-time images. It will be provided with 2 or 3
transducers of different frequency to cater for imaging of various organs. It will have a
printer and "image freeze" capability to facilitate printing of the displayed image. The
unit may have an M-mode facility incorporated for the study of motion.
 Doppler ultrasound is more demanding in terms of both the equipment and the human
resources required. It should be offered at specialized centres of patient care where well-
trained personnel with specialized skills are available. Where the use of such equipment
is appropriate, the ultrasound unit will typically combine real-time imaging with an M-
mode option and Doppler facilities of varying complexity.