Continuing education Med Ultrason 2021, Vol. 23, no.

4, 480-486
DOI: 10.11152/mu-3216

„Knobology“ in Doppler Ultrasound

Axel Löwe1, Christian Jenssen2, Sebastian Hüske3, David Zander3, André Ignee4, Adrian Lim5,
Xin-Wu Cui6, Yi Dong7, Beatrice Hoffmann8, Christoph F Dietrich1

1Department Allgemeine Innere Medizin (DAIM) Kliniken Hirslanden Beau Site, Salem und Permanence, Bern,

Switzerland, 2Department for Internal Medicine, Krankenhaus Märkisch Oderland GmbH Strausberg/ Wriezen and
Brandenburg Institute of Clinical Ultrasound (BICUS) at Medical University Brandenburg „Theodor Fontane“,
Neuruppin, Germany, 3Ruprecht Karls University Heidelberg Medical School, Heidelberg, Germany, 4Department
of Internal Medicine 2, Caritas Krankenhaus, Bad Mergentheim, Germany, 5Imaging Department, Imperial College
Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London UK, 6Department of Medical Ultra-
sound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,
7Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China, 8Harvard Medical School,

Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, USA

Abstract
Ultrasonography is a ubiquitous and indispensable diagnostic and therapeutic tool in medicine. Due to modern equipment
and automatic image optimization, nowadays the introduction of ultrasound imaging requires only little technical and physi-
cal knowledge. However, profound knowledge of the device function repertoire and underlying mechanisms are essential for
optimal image adjustment and documentation. From a medical as well as an aesthetic point of view, the goal should always be
to achieve the best possible image quality. This article provides an overview of handling of ultrasound systems, fundamental
adjustments and their optimization in Doppler ultrasound.
Keywords: guideline; Doppler; ultrasound; perfusion; vascularity

Introduction anatomical structures and topographies, as well as opti-

mal device and image settings, are crucial requirements
The authors recently introduced a series of papers to obtain high quality and reliable US diagnoses.
on how to perform certain techniques [1,2] including In this publication, we aim to illustrate optimal US
“knobology” [3,4]. Doppler ultrasound is an indispen- device settings in a structured and practically applicable
sible imaging tool that is usually employed in addition form, focusing on Pulsed Wave Doppler (PWD) US and
to conventional B-mode sonography. It allows for non- colour Doppler ultrasound (CDUS) [5]. PWD provides
invasive and non-ionizing evaluation of cardiac or vas- information on the blood flow characteristics at a defined
cular blood flow. Compared to other imaging procedures point in a vessel, while CDUS displays the architecture of
such as Magnetic Resonance Imaging (MRI) or Com- the blood vessels in a given field of view within the US im-
puted Tomography (CT), ultrasound (US) imaging, and age as well as direction of flow. When US waves hit mov-
even more Doppler ultrasound, largely depends on the ing objects (e.g., blood cells), the wavelengths and fre-
examiner’s skills and expertise. Adequate knowledge of quencies of reflected US waves change depending on the
flow direction and velocity (Doppler effect). A blood flow
Received 31.01.2021 Accepted 27.02.2021
Med Ultrason
towards the US probe increases US frequency (positive
2021, Vol. 23, No 4, 480-486 frequency shift), while blood flow away from the US probe
Corresponding author: Prof. Christoph F. Dietrich decreases the US frequency (negative frequency shift).
Department Allgemeine Innere Medizin (DAIM), The magnitude of the detected frequency shift is di-
Kliniken Hirslanden Beau Site,
Salem und Permancence, Bern, Switzerland
rectly dependent on the transmission frequency and the
Phone: +41798347180 velocity of the blood flow, but according to the Doppler
E-mail: [email protected] equation it is also influenced by the insonation angle.
 Med Ultrason 2021; 23(4): 480-486 481
2 × blow flow velocity × transmission frequency × cos (insonation angle)
frequency shift =
speed of sound in tissue
The frequency shift caused by blood flow velocities blood flow with very high velocities to circumvent alias-
is in the kilohertz range. It can be displayed acoustically ing (explained in detail below).
and visually. Doppler US imaging requires high intensity Pulse Repetition Frequency / Scale
ultrasound pulses due to the low echogenicity of blood Pulse repetition frequency (PRF) describes the num-
cells. ber of sound pulses that are emitted from the transducer
in one second. The PRF is not related to the transmission
1. Spectral Doppler US frequency. On ultrasound devices, the PRF is often de-
noted as the (velocity) scale, since the PRF determines
Spectral Doppler modalities (PWD and continuous the velocity range or scale (in cm/s) in which flow can be
wave Doppler, CWD) average the differences between represented without aliasing. Flow velocities can only be
transmitted and incoming frequencies over a defined time displayed correctly if their Doppler frequency shift is not
period by Fast Fourier Transformation and display these greater than half the PRF, the so-called “Nyquist limit”.
frequency shifts as a velocity spectrum (hence, the ex- When the frequency shift of the maximum flow velocity
pression “spectral Doppler”). in a given Doppler gate exceeds half the PRF, “aliasing”
CWD systems transmit and receive sound waves con- occurs, a phenomenon whereby portions of the spectral
tinuously with separate piezoelectric crystals in a syn- curve with fast velocities are “truncated” and displayed
chronous fashion, registering every Doppler shift along a below the base line in the reverse flow direction (fig 1).
predefined path. In contrast, PWD systems transmit and Accordingly, the optimal PRF setting is accomplished if
receive series of pulses with the same crystal. In PWD, the maximum flow velocities do not exceed the velocity
the user defines a small “sample volume” or “Doppler range shown on the screen. However, the maximum PRF
gate” in the B-mode image, which is opened after the is limited by the depth localization of the sample volume.
sound waves have travelled through the respective tis-
sue. As a consequence, only Doppler shifts from the
sample volume area are recorded. PWD is a method for
the targeted and selective measurement of flow velocities
in vessels where the exact location of evaluation can be
determined. The nature of intermittent sampling makes
PWD measurements vulnerable to artifacts (i.e., “alias-
ing”) at higher velocities, especially at target structures
that are further away from the transducer [6]. CWD al-
lows detection of very high peak flow velocities (e.g., in
cardiac evaluations) without the ability of pin-pointing
the location of the actual flow [7]. PWD and CWD can
both be activated on the ultrasound scanner console.

Parameter adjustment in PWD

The following important parameters must be consid-

ered in PW Doppler sonography for optimal image ad-
justment.
Transmission Frequency
The spectral Doppler frequency is independent of the
B-mode or colour Doppler frequency. By its adjustment
the examiner maintains spectral Doppler flow sensitivity
in vessels located in the near, mid or far field. Settings are
transducer- and preset-dependent. For deep-seated ves-
sels lower transmission frequencies should be used than Fig 1. Pulse repetition frequency (PRF) of pulse wave Doppler
for vessels located close to the transducer. As a rule, low (PWD) too low (a) and optimized (b). In both images the PRF
Doppler frequency settings should be used to map deep is set much too low with aliasing in both.
482 Axel Löwe et al „Knobology“ in Doppler Ultrasound

Some flow velocities are so high that their measurement

is not possible with standard machine settings. In these
cases, options for improving the exam are:
• optimization of the probe position to shorten the
distance between the vessel and the probe
• selecting a lower transmission frequency
• increasing the scale
• applying a larger angle between vessel and Dop-
pler beam
• shifting the baseline with loss of retrograde flow
components or working with the setting “High Fig 2. The influence on the Doppler spectrum by enhanced
wall filter settings. The filter blanks out signals corresponding
Pulse Repetition Frequency (HPRF)” which is to slower flow.
possible in certain ultrasound machines.
With HPRF, the US system does not wait for the first Gate
Doppler pulse to arrive back at the transducer after re- The size of the gate (Doppler window) should be se-
flection; instead, one or more additional pulses are sent lected with the objective to display the entire available
beforehand, and “ghost gates” are created for each ad- speed range. The size should ideally be at least two thirds
ditional Doppler pulse. This extends the velocity scale of the vessel diameter. In very small vessels it should be
at the expense of the display of slow flow components as small as reasonably applicable.
and the spatial allocation of the Doppler signal. In order Doppler angle
to avoid a mixed signal, it must be avoided that further The Doppler angle must be aligned with the course of
vessels are located in the “ghost gates”. the vessel by use of the respective rotary control or toggle
Baseline switch. This adjustment is crucial for enabling the system
The baseline must be set with the objective to display to calculate the maximum flow velocity and calibrate the
an adequate velocity scale and to make full use of the scale according to the Doppler equation. For Doppler an-
image. gles between 0° and 30°, adjustments are negligible as
Wall Filter the resulting correction of flow velocity is very small.
The wall filter eliminates interfering movements Between 30° and 60°, the Doppler angle should be cor-
(e.g., pulsations) from the vessel wall. At the same time, rected on the device. Since the cosine of 60° is 0.5, omit-
however, slow blood flow components of the spectral ting the angle correction may result in an erroneous dou-
curve (e.g., low end diastolic velocities or a slow reverse bling of the measured flow velocity. With Doppler angles
flow) may not be displayed as the corresponding signals above 60°, exact measurements are no longer possible.
are cut out by the filter settings (fig 2). Image optimi- When exceeding 60°, velocity measurements become in-
zation can thus increase the aesthetics but may conceal accurate despite angle correction. The US devices often
underlying information. Accordingly, wall filters should use a marker to indicate that an adequate angle correction
be used only if necessary to display weak high-frequency is not possible. In those cases, the examiner should try to
signals within high-grade stenoses. The wall filter should find a probe position enabling a Doppler angle of 60° or
be turned off or set low to display very slow flow, e.g., in below (fig 3). Another option is electronic Doppler beam
leg veins, splanchnic veins or diastolic flow components steering, which is possible with modern US systems.
in arterial vessels. Otherwise, a false “no flow” diagnosis Since breathing movements must be avoided during
may be the result. Motion artifacts should be minimized velocity measurements, the examiner should be aware
by optimization at the level of the incoming information, that angle corrections could be performed as part of post-
e.g., by asking patients to hold their breath. processing on most US machines, i.e., after freezing the
Sweep speed image.
Sweep speed adjusts the scrolling speed of the Dop- A flow parameter independent of the Doppler angle is
pler spectrum. A lower sweep speed displays more heart the Pourcelot Resistance Index (RI) which is calculated
cycles, which can be helpful to illustrate certain patholo- from the systolic peak velocity and end diastolic velocity
gies. However, increasing the sweep speed leads to fewer [RI = (peak systolic velocity – end diastolic velocity) /
cycles where each is outlined in greater detail. Sweep (peak systolic velocity)]. It quantifies the pulsatility of
speed can typically be adjusted after recording several blood flow and illustrates the flow resistance downstream
heart cycles; thus, it can be performed after freezing the within the subsequent arterial system and capillary bed.
image (“post-processing”). Another index for the indirect measurement of blood
 Med Ultrason 2021; 23(4): 480-486 483

Fig 3. Measurement of flow velocities in the superior mesenteric artery (SMA): Following adjustment of scale to the velocity range
typical for superior mesenteric artery (95.9 cm/s) and a correction of the Doppler angle to 45° correct measurement of the normal
peak systolic velocity is possible: 145 cm/s (a); in case of no correction of Doppler angle an erroneous low peak systolic velocity is
measured (b; 90 cm/s); improper positioning of the US probe results in a Doppler angle of 72° (c), and correct measurement of flow
velocity is impossible (erroneous measurement of a high peak systolic velocity in the range of mild stenosis)

flow downstream, which is also independent of the angle different colours (usually red and blue) and colour bright-
of insonation, is the Pulsatility Index [PI = (peak systolic ness and shading convey different flow velocities. A third
flow – peak diastolic flow) / (mean flow)]. If it is not fea- colour (green) displays the velocity dispersion. Thus, tur-
sible to adjust the Doppler angle below 60°, one should bulences are visualized. In contrast to the modality men-
refer to Doppler angle independent measurements like RI tioned above, the intensity mode (Amplitude-Doppler /
or PI [8-10]. Power-Doppler / Angiomode) displays only the flow am-
Inversion plitude without flow direction. This allows for a higher
The “Inversion” function interchanges the mapping sensitivity in detecting low-velocity blood flow [11].
of the flow direction as part of the Doppler spectrum. Val- There are two main objectives of CDUS. The first
ues are displayed above or below the baseline depending is to detect the presence of flow, its direction and ac-
on the flow towards or away from the probe. celerations within larger vessels (macro-CDUS). The
Post-Processing second is to visualize perfusion of organs or tumors by
As part of post-processing, the brightness of the im- detecting low-velocity flow in small parenchymal ves-
age can be varied by adjusting the Doppler gain, which sels (micro-CDUS). Micro-CDUS techniques close the
allows for better noise suppression. For arteries, the gain gap to contrast-enhanced ultrasound (CEUS). Different
should be set in a way that a frequency-free window is settings and modalities are used for macro- and micro-
recognizable. In post-processing, the colour of the image CDUS [12,13]. CDUS must be distinguished from other
can also be changed (e.g., monochromatic or polychro- flow imaging modalities. Microvascular Flow Imaging
matic illustration), and the angle correction can be carried (MFI) for example displays blood flow in real-time on
out as described above. In newer machines, the user can the B-scan image. Echoes are encoded, decoded and fil-
edit sweep speed and baseline as well. The knowledge tered in such a way that the significantly weaker echoes
of post-processing alterations is essential particularly in of blood cells are visualized. By comparing successive
measurements acquired in breath hold while examining frames, these weaker echoes are displayed as a flow. Cur-
abdominal vessels. rently, manufacturers have established this technology to
Automatic Image Optimization varying degrees. The advantages are significantly better
Most high-end ultrasound devices can automatically spatial resolution similar to B-scan sonography and bet-
adjust the Doppler settings by changing the parameters ter representation of slow flow with fewer artifacts than
outlined above. Nevertheless, optimum image settings CDUS. Owing to limitations such as a lack of velocity
are best achieved manually. measurement and penetration depth, it is likely that mi-
croflow imaging will increasingly complement CDUS in
2. Colour and Power Doppler US the future without replacing it [14,15].
Other types of MFI make use of traditional Doppler
CDUS integrates B-scan and colour-coding of flow ultrasound techniques with enhanced filters and higher
information. It is often complemented by PWD. CDUS frame rates improving the discrimination between slow
is therefore primarily used for targeted vascular diagnos- flowing signals and background noise. These advanced
tics. Two modes are distinguished. In velocity mode, the Doppler techniques have acronyms such as Superb Mi-
flow direction in relation to the transducer is coded by crovascular Imaging (SMI) (Canon Medical systems)
484 Axel Löwe et al „Knobology“ in Doppler Ultrasound

Fig 5. CDUS aliasing in femoral artery: scale is properly ad-

Fig 4. Low flow Doppler modality (superb microvascular im- justed to the normal velocity range of femoral artery blood flow.
aging, SMI) nicely depicting intrasplenic vessel tree Aliasing indicates stenosis.
or Microvascular Imaging (MVI) (Philips Medical Sys-
tems). They are more sensitive than CDUS and become
increasingly relevant in the field of contrast-enhanced ul-
trasound, which owing to constraints of this article can-
not be explained in detail [16] (fig 4).

Parameter adjustment in CDUS

The following important parameters must be taken

into consideration using CDUS.
Transmission Frequency
The colour Doppler frequency can be adjusted inde-
pendently of the B-scan. Due to the proportionality be- Fig 6. Aliasing with CDUS and PWD in celiac trunk stenosis
tween the transmission frequency and the Doppler fre-
quency, the transmission frequency is important for the 10], aliasing on CDUS is a “red flag” signal for stenosis
sensitivity of flow detection. A compromise between suf- [6] (fig 5, fig 6).
ficient penetration and adequate sensitivity must be found In micro-CDUS a low PRF is used to avoid false neg-
since penetration depth decreases as frequency increases. ative results of vascularization, while with macro-CDUS,
Pulse Repetition Frequency / Scale higher PRF settings would prevent aliasing (fig 7, fig 8).
The PRF defines the velocity range on display. If the Baseline
maximum flow velocity on the scale is exceeded, alias- The baseline alters the display of the flow velocity
ing artifacts occur. If the scale is correctly adjusted to the range as it is moved up or down. On CDUS, baseline
flow velocity that can be expected in a given vessel [8- adjustment is of no clinical value.

Fig 7. Adjustment of velocity scale in colour Doppler of a focal thrombus of the femoral vein: low scale (2.3 cm/s), aliasing with
thrombus (*) poorly visibly (a); high scale (62.3 cm/s), nearly no flow is visible and complete thrombosis is feigned (b); adequate
scale (11.7 cm/s) showing venous blood surrounding the focal thrombus (c)
 Med Ultrason 2021; 23(4): 480-486 485

Fig 9. Influence of beam steering on visualization of slow post-

occlusive flow in tibial artery. Scale was adjusted to low flow
velocities (3.8 cm/s): no beam steering with poor visibility of
Fig 8. Influence of scale adjustment in CDUS of superior mes- flow (a). Beam steering (b: 15°; c: 30°) improves visibility and
enteric artery (normal velocity range 100 – 200 cm/s): alias allows correct PWD measurement of the peak systolic velocity
phenomenon due to improper low selection of scale (13.7 cm/s) (9.7 cm/s) with an acceptable Doppler angle of 44° (d)
simulates stenosis (a); Correction of scale to the velocity range
typical for superior mesenteric artery (95.9 cm/s) shows normal
blood flow (b) but this can lead to confusion if not all providers use the
same inversion option.
Colour Doppler box Gain
The sampling box, in which the flow is displayed, The gain of colour Doppler should be initially in-
should be as small as possible and as large as necessary. A creased until so-called “blooming” artifacts occur fol-
smaller box size increases temporal resolution and frame lowed by a gradual gain reduction until these artifacts
rate. Using the trackball or touchpad and the “set” button disappear (fig 10).
can optimize the size and position of the box. When us-
ing linear array transducers, the examiner can steer the
insonation angle. The smaller the Doppler angle between
the transducer and the vessel of interest, the better and
more accurate the retrieved flow information (fig 9).
Doppler angle and steering
The Doppler angle should be at or below 60° as an-
gles above this threshold will compromise the colour dis-
play of blood flow, owing to the fact that the cosine of an
insonation angle above 60° in the Doppler equation leads
to erroneous flow velocities and cannot be compensated
by manual or technical corrections. In the case of linear
arrays, steering of the Doppler angle is possible but re-
duces the sensitivity of flow detection. Therefore, it is
preferable to position the transducer carefully in the first
place with the objective of acquiring a smaller Doppler
angle between 0 and 30°.
Inversion
The colour spectrum is interchangeable by pressing
the “invert” button. Since colours are selected individual-
ly, the flow pattern on display should be interpreted with
the colour bar on the right or left edge of the screen. By
default, flow towards the transducer is coded in red, and Fig 10. Gain optimized (a), and too high with additional colour
flow away from the transducer is depicted blue. Inversion artifacts, so-called “blooming” phenomenon, around the actual
can be helpful to display arteries in red and veins in blue vessels (arrows) (b).
486 Axel Löwe et al „Knobology“ in Doppler Ultrasound

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Conflict of interest: none
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