Você está na página 1de 7

The clinical application


of Doppler techniques
demands more
sophisticated equipment
than is used for traditional
two-dimensional, grey-scale

Doppler ultrasound examination

in dogs and cats

THIS is the first of three articles about Doppler ultrasound and its role in the investigation of diseases
in dogs and cats. For small animal practitioners already familiar with two-dimensional, grey-scale
ultrasonography, Doppler ultrasound represents the next level of sophistication, and is a more technically
demanding modality. These articles aim to provide a basis for an understanding of the techniques and
to assist in case selection, both for practitioners wishing to perform these studies and those requesting
examinations by specialists. This first article describes the Doppler principle and the different types of
Doppler techniques that are used for diagnosis. The second and third articles, to be published in the
Chris Lamb is Senior
May and June issues, will discuss the applications of Doppler ultrasound in the abdomen and in the Lecturer in radiology
assessment of cardiac diseases, respectively. in the Department
of Veterinary Clinical
Sciences at The Royal
Veterinary College
THE DOPPLER EFFECT diplomate of both the
American College of
Veterinary Radiology
Sound is mechanical energy in the form of pressure and the European
College of Veterinary
waves that travel through a medium by transferring ener- Diagnostic Imaging.
gy from one particle to the next. The velocity of sound is
determined by the rate at which energy is transferred.
Denser materials, which contain closely packed parti-
cles, transmit sound faster than less dense materials.
The speed of sound in tissue is approximately 1540 m/
Ultrasound is defined as sound at a frequency above
the audible range – that is, any sound with a frequency
greater than 20,000 Hz. Medical diagnostic ultrasound
Adrian Boswood
machines use frequencies in the range 2 to 15 million Hz Example of the Doppler effect. is Senior Lecturer in
(MHz), because these frequencies have a short wave- The pitch of the siren of an internal medicine in
ambulance appears to be higher the Department of
length in tissue, which is necessary for adequate resolu- when approaching the observer Veterinary Clinical
tion of anatomical details. and lower as the ambulance Sciences at The RVC.
speeds away. For the driver of the He is an RCVS
Doppler ultrasound techniques are based on the prin- ambulance, the pitch of the siren specialist in veterinary
ciple of Doppler shift – that is, a change in the frequency remains constant cardiology and holds
of sound that is observed when the source is moving the European College
of Veterinary Internal
relative to the observer. A familiar example of Doppler original ultrasound pulse if the RBCs are moving Medicine’s cardiology
shift is the change in pitch of a siren on a passing ambu- towards the transducer and a lower frequency if the diploma. His main
area of interest is
lance or police car, which is high on approach, then RBCs are moving away from the transducer (as illustrat- small animal
suddenly becomes lower as the vehicle moves away. In ed at the top of page 184). Echoes originating from sta- cardiorespiratory
medical ultrasound, this principle may be used to detect tionary objects in the body will have the same frequency medicine.

and measure the flow of blood because red blood cells as the transmitted ultrasound beam (ie, there will be no
(RBCs) reflect ultrasound waves, producing echoes that Doppler shift).
can return to the transducer. The echoes returning from RBCs are very small (diameter 7 µm) compared to a In Practice (2005)
moving RBCs will have a higher frequency than the typical ultrasound wavelength (0·2 to 0·5 mm), and they 27, 183-189

In Practice ● APRIL 2005 183


Continuous wave Doppler uses two transducers simulta-

neously: one transmitting a focused ultrasound beam, the
other receiving echoes (as illustrated below). A device in
the ultrasound machine known as a directional demodu-
lator compares the transmitted frequency and the fre-
quency of any received echoes, and outputs a signal that
is either positive or negative depending on whether the
(A) (B)
frequency of echoes is increased (positive Doppler shift)
Origin of the Doppler shift in blood vessels. (A) 5 MHz ultrasound beam reaching red blood or decreased (negative Doppler shift). This signal is fed
cells (RBCs) moving away from the transducer. (B) Echoes originating from these moving through a spectrum analyser producing a graphical out-
RBCs have an altered frequency because the ultrasound waves are either bunched together
(ie, wavelength is reduced in the same direction as flow) or spaced out (ie, wavelength is put of Doppler shift versus time (see below).
increased in the opposite direction to flow). A transducer facing the approaching RBCs will In continuous wave Doppler, echoes may originate
receive echoes with a frequency greater than 5 MHz, whereas a transducer facing the
retreating RBCs will receive echoes with a frequency lower than 5 MHz from blood vessels anywhere within the region where
the transmitted ultrasound beam overlaps with the field
of view of the receiver. This is an elongated zone; hence,
it is not possible to determine accurately from what
produce echoes that are much weaker than the echoes depth echoes are returning. On the other hand, continu-
from tissues. The intensity of ultrasound echoes from ous wave Doppler is a technique that enables accurate
RBCs is proportional to the fourth power of frequency, measurement of high velocity blood flow in the heart or
hence Doppler signals have higher amplitude at higher large arteries, which makes it very useful for the diagno-
ultrasound frequencies; however, this effect is balanced sis of conditions such as aortic stenosis.
by the increased attenuation of higher frequency ultra-
sound in tissue. Because of the low amplitude of
Doppler signals compared to echoes used for grey-scale
imaging, the optimal Doppler frequency must be lower
than the optimal frequency for grey-scale ultrasound
imaging at a comparable depth, in order to minimise
attenuation of the echoes (see below).

Principle of continuous wave Doppler.

A continuous ultrasound beam is
emitted from one part of the transducer
(transmitter, T) while returning echoes
(arrow) are detected by another part
(receiver, R). Using a spectrum analyser,
the frequency of echoes is compared
with the frequency of the original
LV beam; the difference equals the Doppler
shift. Echoes may originate from
Echoes from RBCs are very anywhere in the zone where the
weak. (right) Blood normally LA transmitted beam overlaps with the
appears virtually anechoic in field of view of the receiver (darker
grey-scale ultrasound images grey shaded area)
because it generates much
weaker echoes than tissues
such as the myocardium.
Ao Aorta, LV Left ventricle,
LA Left atrium.
(below) Maximum useful
depth plotted against ultrasound frequency. In order to minimise the attenuation of weak
echoes originating from RBCs, Doppler techniques must use a lower frequency of ultrasound 4
than grey-scale ultrasound imaging at any particular depth


1 2 3

Depth (cm)



Example of a Doppler spectrum obtained from the

pulmonary artery of a dog using a continuous wave
technique at 2·5 MHz. The vertical axis is Doppler shift in kHz:
positive shifts (increase in apparent frequency) represent
flow towards the transducer and negative shifts represent
5 flow away from the transducer. The horizontal axis is time
in seconds (with subdivisions every 0·2 seconds). An
echocardiogram (green line) is used to determine the stage
of the cardiac cycle. There is high velocity systolic flow away
0 from the transducer (1 to 3), which represents the cardiac
2·5 3·5 5 7 output, and lower velocity diastolic flow towards the
Frequency (MHz) transducer (4), which is the result of pulmonic insufficiency

184 In Practice ● APRIL 2005


The apparent change in frequency of echoes returning

to the transducer – the magnitude of the Doppler shift –
depends on the direction of the ultrasound beam com-
pared with the direction of flow. The maximum (true)
Doppler shift is observed when the ultrasound beam is
aligned with the axis of flow. If the ultrasound beam is
at an angle to the flow, a reduced Doppler shift will be
detected and if the ultrasound beam is perpendicular to
the flow, there will be no Doppler shift because blood
flow is neither towards nor away from the transducer (see
The magnitude of the Doppler shift depends on the
right). In practice, it is not always possible to place the orientation of the transducer relative to the direction of
transducer on the body in a position that perfectly aligns blood flow. The maximum Doppler shift is obtained when
the ultrasound beam is directed along the same axis as
the ultrasound beam with flow – and a so-called ‘angle of blood flow (left). If the ultrasound beam is at an angle
insonation’ (ie, angle between the ultrasound beam and to the flow, the Doppler shift will be reduced (middle).
If the ultrasound beam is perpendicular to the flow, no
axis of flow) is produced. Many abdominal vessels, for Doppler shift will be detected (right) because, under these
example, have a longitudinal alignment but must be circumstances, blood flow is neither towards nor away from
the transducer. fD Doppler shift, t Time
examined from windows on the lateral or ventral aspects
of the abdominal wall. This makes it difficult to minimise
the angle of insonation. A similar problem affects cardiac
The blood flow velocity is
Doppler studies and the transducer positions used for proportional to the Doppler
Doppler studies are different to those used for two- shift and may be calculated
using the formula given here.
dimensional, grey-scale echocardiography. For example, v Blood flow velocity,
optimal Doppler studies of flow in the ascending aorta in fD Doppler shift, c Speed of
ultrasound propagation in
the dog are performed by placing the transducer just cau- tissue, f Frequency emitted by
dal to the xiphoid process and directing the beam cranial- transducer, θ Angle between
ly through the liver (known as the subcostal window). ultrasound beam and direction
of flow. Inclusion of the value
Ultrasonographers normally attempt to place the cosθ in the denominator makes
transducer in positions that minimise the angle of it possible to correct for the
angle between the ultrasound
insonation but, providing the angle can be measured, it is beam and the direction of flow.
possible to use the observed Doppler shifts to calculate Ultrasound machines can
calculate this automatically
the velocity of moving ultrasound reflectors using the once a value for θ has been
formula given below (see also right): selected by the operator and,
therefore, the Doppler spectrum
is usually displayed with a
vertical scale in m/seconds

v= fD.c
where v = Blood flow velocity, fD = Doppler shift,
It is important to maintain a fairly small angle of
f = Frequency emitted by transducer, c = Speed of
insonation when attempting to measure blood flow veloc-
ultrasound propagation in tissue, cosθ = Cosine of
ity because the effect of any error in angle measurement
the angle of insonation
is magnified at wider angles. Cardiologists use windows
that align the Doppler beam within 15º of blood flow
and ultrasonographers examining abdominal or peripheral
30 vessels attempt to use angles of insonation of less than
The magnitude of the Doppler shift is given by the
10 MHz

20 Limit of audible range

Doppler shift (kHz)

fD = f(2v/c-v)
where fD = Doppler shift, f = Frequency emitted by
transducer, v = Blood flow velocity, c = Speed of
ultrasound propagation in tissue
10 5 MHz

It is interesting to note that the speed of sound

2 MHz in tissue (1540 m/second) is roughly 1000 times the
typical blood flow velocity (1 to 2 m/second) and hence
0 fD ≈ f/1000. Therefore, if the frequency of the ultrasound
0 1 2 3 4 5
beam is in MHz, the frequency of a typical Doppler shift
Blood flow velocity (m/second)
is in kHz, which makes the Doppler shift audible (see
The Doppler shift is proportional to blood flow velocity and graph on the left). This useful coincidence allows us to
is usually audible when using 2 or 5 MHz ultrasound. Doppler
shifts for blood flow velocities greater than 3 m/second listen to Doppler signals, which aids recognition of
exceed the audible range when using 10 MHz ultrasound abnormalities.

In Practice ● APRIL 2005 185

Principle of pulsed wave
Doppler ultrasonography.
The Doppler shift is
collected from echoes (A) Plug flow
originating in a sample
volume at a particular depth
in the ultrasound beam. The Depth of sample volume
depth of the sample volume
is determined by the delay
Thickness of sample
between production of
volume (‘gate’)
the ultrasound pulse and
switching on the receiver. (B) Laminar flow
The thickness of the
sample volume (‘gate’) is
determined by the time the
receiver is active. The width
Width of sample volume
of the sample volume is
equal to the width of the
ultrasound beam

PULSED WAVE DOPPLER (C) Disturbed flow

Pulsed wave Doppler uses short pulses of ultrasound

emitted at regular intervals by the transducer; echoes
The appearance of the pulsed wave Doppler spectrum varies
from a specific depth are collected by switching on the according to the type of blood flow. (A) In the ascending
receiver briefly at the time echoes are expected to return. aorta there is normally plug flow, in which all the RBCs
accelerate and decelerate together, so the Doppler spectrum
The thickness of the sample volume (the ‘gate’) from is a line with a lack of signal (*) beneath it. (B) In most small
which echoes are collected may be increased by keeping arteries there is laminar flow, in which the RBCs have a
range of velocities (with those in the centre of the vessel
the receiver active for a longer period. The width of the flowing fastest); hence, the Doppler spectrum shows a range
sample volume is determined by the width of the ultra- of velocities, with values between the maximum and
baseline at any given point in time. This is known as spectral
sound beam (see above). The adjustable sample volume
broadening. Use of a large sample volume, a wide angle of
in pulsed wave Doppler enables Doppler shifts to be insonation and vessel tortuosity also contribute to spectral
collected from specific locations in the body. Thus, broadening. (C) In vessels containing disturbed flow (eg, as
a result of stenosis), the Doppler spectrum will show an
small vessels can be examined individually, which is not increased peak systolic velocity (large arrow) and a signal
possible using continuous wave Doppler. below the baseline (small arrow), which occurs because of
flow reversal
When a mechanical transducer is used for either con-
tinuous wave or pulsed wave Doppler, it is necessary to
stop movement of the piezoelectric element to allow
Doppler acquisition, which freezes the grey-scale image The appearance of a pulsed wave Doppler spectrum
on the screen. Transducers using electronic arrays permit describes the pattern of blood flow in a blood vessel.
rapid switching between the two-dimensional, grey-scale Recognition of different patterns of flow can help to
ultrasound image and Doppler acquisition, enabling both identify the vessel. For example, the caudal vena cava
to be displayed together – this is the origin of the expres- has variable flow in a rather complex pattern because of
sion ‘duplex Doppler’ (see below). the effect of the cardiac and respiratory cycles. The
portal vein, which has capillaries at its origin and hepatic
sinusoids at its termination, is relatively insulated from
variable blood flow and, therefore, has a relatively con-
stant, low velocity flow towards the liver. Arteries may
be readily distinguished from veins because of their
pulsatile flow, but the appearance of the Doppler spec-
trum varies between arteries and may change if there is
disease (see above).


It is not always possible to display blood flow velocities

accurately in a Doppler spectrum. In addition to the
problem of correcting for the angle of insonation, high
velocity flow may exceed the available range for display.
The maximum Doppler shift that may be measured in
pulsed wave Doppler is known as the Nyquist limit and
is determined by the pulse repetition frequency (PRF).
Example of a simultaneous two-dimensional, grey-scale and pulsed wave Doppler acquisition This is the frequency at which pulses of ultrasound are
(‘duplex Doppler’). A sample volume (indicated by short parallel white lines) has been
positioned using a track ball in the abdominal aorta of a dog. The sample volume depth is 44 mm emitted by the transducer. The Nyquist limit is equal to
and the gate is 4 mm (data circled in red). An angle correction of 63° has been applied by the half the PRF; hence, it is necessary to use a PRF of at
operator (indicated by the lines each side of the sample volume) according to the long axis of
the aorta. The Doppler spectrum is displayed with a vertical scale in m/second. Normal
least double the observed Doppler shift in order to accu-
pulsatile flow with a peak systolic velocity of 2 m/second is observed rately display flow velocity. If the PRF is set too low and

186 In Practice ● APRIL 2005

Aliasing. If the blood flow velocity exceeds the Nyquist limit
part of the Doppler signal will be displayed on the wrong side
of the baseline, appearing as if it were flow in the opposite
direction. (A) Doppler spectrum of the carotid artery in which
the peak systolic velocity exceeds the velocity range and
results in a signal below the baseline (arrows). (B) The
velocity range has been increased (by increasing the PRF)
(A) (B) so that it now encompasses the peak systolic velocity, which
is correctly displayed

blood flow velocity exceeds the Nyquist limit, part of the

Doppler signal will be displayed on the wrong side of
the baseline, appearing as if it were flow in the opposite
direction (see above). When this is observed, it is neces-
sary to increase the PRF. Alternatively, if the PRF is
already set at its maximum value, it may be possible to
bring the Doppler signal to the same side of the spectrum Grey-scale image Multiple small Colour-coding of Doppler
of tortuous vessel sample volumes shifts superimposed on
by moving the baseline, which increases the available
grey-scale image
range in one direction. Using a lower frequency also
The principle of colour Doppler ultrasonography is
reduces aliasing. If none of these adjustments is suffi- illustrated in this diagram, which shows a tortuous blood
cient to avoid aliasing, it may be better to use continuous vessel (small white arrow indicates direction of flow).
Multiple small sample volumes are activated in sequence
wave Doppler, which does not suffer from aliasing.
(large arrow) using the same principle as described for
pulsed wave Doppler. The Doppler shift for each sample
volume is rapidly calculated, and shifts above or below a
certain threshold are colour-coded. In this diagram, positive
COLOUR DOPPLER Doppler shifts are colour-coded red, and negative shifts
blue. By covering a large part of the image, colour flow
Doppler enables sites of blood flow to be readily identified.
Colour Doppler ultrasonography is an advanced form of Note that where the vessel is perpendicular to the
pulsed wave Doppler in which the ultrasound machine ultrasound beam (eg, at the bottom of each bend) there
is no Doppler shift, and hence the colour flow image does
rapidly collects Doppler shifts from a large number of not precisely depict flow
small sample volumes and displays the Doppler shift as a
colour superimposed on the grey-scale image (see above
right). Colour Doppler requires several pulses of ultra-
sound per scan line in order to calculate the mean Doppler Nyquist limit
shift for each sample volume. This results in a lower frame
rate than for grey-scale imaging at a comparable depth,
Increasing positive Doppler shift Interpretation of a colour map.
which may be a problem when attempting to examine flow
Lack of Doppler shift (baseline)
in a rapidly moving structure, such as the heart. produces no colour. Positive shifts
The mean Doppler shift for each sample volume may Baseline (no flow) are depicted by colours towards
the top of the map, and negative
be colour-coded according to direction, velocity, ampli- Doppler shifts by colours towards
tude and variance (which is the range of velocities within the bottom. The Nyquist limit –
Increasing negative Doppler shift 0·30 m/second in this instance –
the sample volume) (see right). Various colour maps
represents the maximum velocity
may be used (see below) and it is important to refer to that may be displayed correctly
the corner of the screen where the map is displayed Nyquist limit using the map. A band of green
along the right edge of the map is
before interpreting the image. Red and blue are used used to depict increasing variance
to depict the direction of blood flow (not to distinguish Increasing variance in Doppler shifts
arteries and veins): the usual convention for displaying
colours is ‘BART’ – blue away, red towards (see right).



Variance maps
Colour Doppler image of the liver of a dog. Flow in portal
Examples of different colour maps. In each of the maps on branches (PV) is in the opposite direction to flow in hepatic
the left, positive Doppler shifts are colour-coded red or veins (HV). Note the colour map in the top left corner, which
yellow whereas negative Doppler shifts are colour-coded explains the meaning of the various colours displayed: red
blue or green. The group of maps on the right have an represents flow towards the transducer, and blue flow away
additional colour along their right edge to depict variance from the transducer. Flow in the caudal vena cava (CVC) is
in Doppler shifts aliased (see text)

In Practice ● APRIL 2005 187




(A) (B)

Use of colour Doppler ultrasonography in a cat with a ventricular septal defect (VSD). (C)
(A) Two-dimensional grey-scale image obtained from a right intercostal window shows the
VSD as a focal lack of echoes in the interventricular septum (arrow). RV Right ventricle,
LV Left ventricle, LA Left atrium. (B) Corresponding colour Doppler image shows red-coded flow from the left ventricle towards the VSD that turns into
a multicoloured pattern through the VSD and in the right ventricle. The blue shades indicate aliasing; in other words, the blood flow velocity exceeds the
Nyquist limit (0·64 m/second) and so cannot be correctly depicted by the colour map. (C) Continuous wave Doppler spectrum obtained using the colour
Doppler image as a guide. Peak blood flow velocity through the VSD exceeds 5·5 m/second. This is a more accurate assessment of flow velocity than was
possible using the colour Doppler image. Turbulent flow is indicated by simultaneous negative Doppler shifts (curved arrow)

Colour Doppler enables the presence of flow in the The problem

of displaying
area encompassed by the ultrasound image to be rela- blood flow
tively easily and rapidly assessed. This aids recognition in vessels
of sites of abnormal flow that may need quantitative to the
assessment by continuous wave or pulsed wave Doppler. transducer.
In practice, colour Doppler is mainly used for initial (A) When using
a sector (A)
qualitative assessment of the presence and direction of transducer and
blood flow and then as a guide to placement of continu- directional
colour Doppler,
ous wave or pulsed wave sample volumes (see above). flow in the
Colour Doppler may also be used in conjunction with relatively
straight carotid
M-mode ultrasonography (see below). artery is
divided into
flow towards
the transducer
(red), parallel
flow (no signal)
Aortic insufficiency and flow away
(blue). (B) When
using a linear
flow is
throughout the
sample volume
and the (C)
Mitral insufficiency ambiguity leads
to display of a
colour mosaic made up of red, blue and black. (C) When
using a linear transducer, the colour box may be angled
Diastole Systole electronically so that there is a constant angle between
flow and the ultrasound beam. In this example, the colour
Colour Doppler may be used in combination with M-mode ultrasonography, particularly box has been angled to the right (large arrow) and flow is
when examining the heart. This M-mode image shows abnormal, heterogeneous colour-flow now correctly depicted as towards the transducer. Note
signals in the root of the aorta (Ao) during diastole and in the left atrium (LA) during slight aliasing in the middle of the artery (small arrow).
systole. These findings indicate aortic insufficiency and mitral insufficiency, respectively. When using a sector transducer, an angle between the
The use of M-mode ultrasonography in combination with colour Doppler enables accurate ultrasound beam and direction of flow may be adjusted
timing of abnormal blood flow during the cardiac cycle manually by repositioning the transducer

(A) (B) (C)

Aliasing in colour Doppler. Just as described for pulsed wave Doppler, any flow velocities that exceed the Nyquist limit will be displayed on the wrong side
of the baseline. (A) Colour Doppler image of the carotid artery in which the velocity range is too low (0·029 m/second) and the signal is aliased, appearing as
a mixture of colours with red, white and blue merging. (B) The velocity range has been increased (0·69 m/second) and aliasing has been eliminated, so that
the flow appears correctly (ie, is unidirectional); however, the velocity range is now too high and lower velocity flow is not displayed, resulting in a lack of
signal from the margins of the vessel lumen. (C) Correctly adjusted velocity range (0·23 m/second). Doppler signal fills the vessel and there is minimal

188 In Practice ● APRIL 2005


Increased sensitivity to flow makes power Doppler a useful

method for evaluating global organ vascularity. In this
instance, the technique is used to demonstrate the blood
vessels in a normal canine left kidney

Example of power Doppler imaging in the common carotid SUMMARY OF DOPPLER TECHNIQUES
artery. (A) This image includes no directional information
but shows a single continuous colour-flow signal even Continuous wave Pulsed wave Colour Doppler Power Doppler
where flow is perpendicular to the ultrasound beam.
(B) Although power Doppler is more sensitive to flow at Quantitative assessment ++ + + –
wide angles of insonation, it is nevertheless based on the of blood flow
same Doppler shift principle as other Doppler techniques.
Increasing the scale to 0·30 (from 0·075 in A) results in a Global view of blood flow – – ++ ++
reduced signal where flow is perpendicular to the within an organ
ultrasound beam
– Not used, + Moderately useful, ++ Optimal method

Colour Doppler shares many features with pulsed

wave Doppler, including aliasing and a lack of Doppler
shift when the ultrasound beam is perpendicular to flow perpendicular to the ultrasound beam (see above left).
(as illustrated on page 188). For these reasons, power Doppler is more sensitive to
low flow velocities in smaller vessels, which makes it a
better technique than colour Doppler for assessing the
POWER DOPPLER vascularity of organs (see above right).

Power Doppler (known variously as ‘colour Doppler

energy’ and ‘power angio’) is a form of colour Doppler SUMMARY
Further reading
imaging that has been developed to map only the magni- KREMKAU, F. W. (2002)
tude (or power) of Doppler signals. Colour in power A range of Doppler techniques may be used to detect Diagnostic Ultrasound –
Principles and Instruments,
Doppler represents the magnitude of the Doppler shift – and measure blood flow in the body and these are sum- 6th edn. Philadelphia,
the direction of flow is not displayed using this tech- marised in the table above. They are based on physical W. B. Saunders
nique. There is a greater degree of frame-averaging in principles beyond those employed in two-dimensional, This is generally considered to
be one of the best books on
power Doppler, which increases the signal-to-noise ratio grey-scale ultrasonography. The clinical application of this subject, providing clear
and sensitivity compared with colour Doppler. Power Doppler techniques demands more sophisticated equip- explanations of the principles
and detailed descriptions of the
Doppler is also less angle-dependent than colour ment, an understanding of the technicalities and a higher technicalities of modern
Doppler and, therefore, is able to display flow that is level of scanning expertise. ultrasound systems

Registered Charity 287118

In Practice ● APRIL 2005 189