Mock Exam_Physics SPI Bk Cvr:Layout 1 10/21/09 9:31 PM Page 1 Looking for guidance and a clear understanding of the principles and facts on which you will be tested? Here is the new SPI edition of the single bestselling mock exam devoted to the ARDMS exam in ultrasound physics. Written by an internationally renowned sonographer who not only loves ultrasound physics but delights in—and excels at—explaining it to others, Ultrasound Physics Review hones your test-taking skills, measures your progress as you study, and reveals your strengths and weaknesses topic by topic. Contains 600 complex registry-style questions that cover and follow the new ARDMS Sonography Principles and Instrumentation (SPI) outline, 65 image-based questions, and simple, clear explanations with current references for further study. Coverage includes patient care, safety, and communication, physical principles, ultrasound transducers, pulse-echo instrumentation, Doppler instrumentation and hemodynamics, and quality assurance/quality control of equipment—all in the same proportion as in the exam itself. Especially effective in combination with the Davies specialty exam reviews in Vascular, Abdomen, Ob/Gyn, Adult Echo, Fetal Echo, and Breast. Why are our mock exams so popular and effective? Because they contain the same kinds of thought-provoking questions you will find on the exam! 12 hours’ SDMS-approved CME. Davies catalog #11030. About the authors . . . Cindy Owen, RT, RVT, RDMS, FSDMS, is the author of Abdominal Sonography Review, ScoreCards for Vascular Technology, Ultrasound Physics Review, and the related CD-ROM Mock Exams. A former ARDMS and ICAVL board member, she is Global Manager of Luminary & Research Programs at GE Healthcare and lectures widely throughout the world. Cindy lives with her family in Memphis. James A. Zagzebski, PhD, is Professor and Chair of the Department of Medical Physics at the University of Wisconsin, Madison, and the author of Essentials of Ultrasound Physics. In addition to his teaching, research, and writing, Dr. Zagzebski has lectured widely over the years, helping thousands of registry candidates pass their physics exam. The New CD-ROM Mock Exams from Davies are the most effective and featuresome CDs available. Interactive, fun, and packed with regularly updated peer-reviewed content for SPI, Abdomen, Vascular, Ob/Gyn, Breast, and Fetal Echo. Work in Test Mode or Study & Learn Mode and easily customize your Test and Study sessions to focus on specific exam topics. Hundreds of continuously variable questions and images in registry format sharpen your wits and ensure your knowledge of underlying principles and facts. Clear, simple explanations and current references illuminate answers. Expert tutorials cover key concepts in depth. Additional explanatory images and illustrations further clarify answers, anatomy, and pathology. Test timer keeps you on track. Instant results analysis scores and guides you topic by topic. Automatically review missed questions with one click. Available CME credit. A snap to use. Bonus feature: Contact directory of key organizations and societies, including ARDMS, SDMS, ARRT, CCI, ACR, and SVU. Order toll-free 1-877-792-0005 or download from our website. ISBN 0-941022-74-9 www.DaviesPublishing.com DAVIES Ultrasound Physics Review: SPI Edition ii Ultrasound Physics Review A Q&A REVIEW FOR THE ARDMS SPI EXAM 2016 Cindy A. Owen, RT, RVT, RDMS, FSDMS Director, Clinical Insights and Development GE Healthcare, Point of Care Ultrasound James A. Zagzebski, PhD Professor Emeritus Department of Medical Physics University of Wisconsin Editor in Chief Ultrasound Physics Review | SPI Edition iii v Copyright © 2016, 2015, 2014, 2013, 2012, 2011, 2010, 2009 by Davies Publishing, Inc. All rights reserved. No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic or mechanical, including photocopying, scanning, and recording, without prior written permission from the publisher. Davies Publishing, Inc. 32 South Raymond Avenue Pasadena, California 91105-1961 Phone 626-792-3046 Facsimile 626-792-5308 Email info@daviespublishing.com www.daviespublishing.com Printed and bound in the United States of America ISBN 0-941022-74-9 Library of Congress Cataloging-in-Publication Data Owen, Cindy. Ultrasound physics review : a review for the ARDMS SPI exam / Cindy A. Owen ; James A. Zagzebski, editor in chief. p. ; cm. Includes bibliographical references. ISBN 0-941022-74-9 1. Diagnostic ultrasonic imaging--Examinations, questions, etc. 2. Ultrasonics--Examinations, questions, etc. 3. Medical physics--Examinations, questions, etc. I. Zagzebski, James A. II. Title. [DNLM: 1. Ultrasonography--Examination Questions. 2. Ultrasonics--Examination Questions. 3. Ultrasonography--instrumentation--Examination Questions. WN 18.2 O967u 2009] RC78.7.U4O966 2009 616.07'543--dc22 2009024704 Ultrasound Physics Review | SPI Edition iv Preface T is a question/answer/reference review of ultrasound physics for ARDMS candidates who plan to take the Sonography Principles and Instrumentation (SPI) examination for one or more ARDMS credentials. It is designed as an adjunct to your regular study and as a method to help you determine your strengths and weaknesses so that you can study more effectively. HIS MOCK EXAM Facts about this updated SPI Edition of Ultrasound Physics Review: § It covers the topics covered in the current ARDMS exam outline. § It focuses exclusively on the SPI exam to ensure thorough coverage of even the smallest subtopic on the exam. (For the ARDMS specialty exams in Vascular Technology, Abdomen, Ob/Gyn, Breast, Adult Echocardiography, and Fetal Echocardiography, see our exam-specific reviews and mock exams at www.DaviesPublishing.com.) § We refer to the last best ARDMS content outline as a guideline for coverage. At the same time, we organize the content using a comprehensive, subject-driven approach to ensure that all important topics are fully addressed. The ARDMS exam outline provides a generalized categorical overview together with very specific clinical tasks, but it can miss key intermediate topics you must know to pass your exam. Hence our hybrid approach gives you the best of both worlds. § Ultrasound Physics Review contains nearly 600 questions, many of which are image-based or otherwise illustrated. § Explanations are clear and conveniently referenced for fact-checking and further study. § The SPI exam includes the new Advanced Item Type (AIT) questions that assess practical sonography instrumentation skills. These include SemiInteractive Console (SIC) questions. The material you need to know to answer these AIT questions is in our SPI mock exam; there just isn’t a virtual console. For instance, our review contains a question that has an image of poor quality and asks you what to do in order to optimize it. Perhaps the answer is, “Decrease gain.” If so, you choose that answer. On the semi-interactive console you answer it by using your computer’s Ultrasound Physics Review | SPI Edition v mouse to adjust the gain control, decreasing it to optimize the poor image in the question. That’s the difference. § Each of these semi-interactive console questions is marked “AIT–SIC” to help you locate SIC items. AIT–SIC questions constitute about 10% of the 110-question SIC exam, according to ARDMS’s website. AIT–SIC questions constitute approximately 19% of Davies’ mock exam—more than 100 questions. § The ARDMS exam outline and contact information for the ARDMS appears in Part 8 at the end of the book. Ultrasound Physics Review effectively simulates the content and the experience of taking the exam. Current ARDMS standards call for approximately 110 multiple-choice questions to be answered during a two-hour period. That is, you will have an average time of 1 minute to answer each question. Timing your practice sessions according to the number of questions you need to finish will help you prepare for the pressure experienced by ARDMS candidates taking the SPI exam. It also helps to ensure that your practice scores accurately reflect your strengths and weaknesses so that you study more efficiently and with greater purpose in the limited time you can devote to preparation. ARDMS test results are reported as a “scaled” score that ranges from a minimum of 300 to a maximum of 700. A scaled score of 555 is the passing score (the “passpoint” or “cutoff score” for all ARDMS examinations). The scaled score is simply a conversion of the number of correct answers that also, in part, takes into account the difficulty of a particular question. Google Angoff scoring method if you want to learn more about scaled scoring. Suffice it to say that it helps to ensure the fairness of the exams and that in the case of all ARDMS exams 555 is the minimum passing score. We include below and strongly recommend that you read Taking and Passing Your Exam, by Don Ridgway, RVT, who offers useful tips and practical strategies for taking and passing the ARDMS examinations. Finally, you have not only our best wishes for success, but also our admiration for taking this big and important step in your career. Cindy Owen Cindy Owen, RT, RVT, RDMS, FSDMS Ultrasound Physics Review | SPI Edition 100 PART 5 Doppler Instrumentation and Hemodynamics Ability to acquire color flow image Ability to acquire a Doppler spectral image Ability to take measurements from the spectral waveform Hemodynamics 451. What is the maximum velocity limit for a 3 MHz CW Doppler unit operating at a depth of 4 cm? A. B. C. D. E. 40 cm/s 200 cm/s 2.5 m/s 4 m/s None of the above 452. You will see aliasing of the Doppler spectrum whenever the frequency shift exceeds: A. B. C. D. E. Twice the pulse repetition frequency Three times the pulse repetition frequency One-third the pulse repetition frequency One-half the pulse repetition frequency One-fourth the pulse repetition frequency 453. You obtained this color Doppler image while performing hepatic sonography. There is no color signal detected within the portal vein. What can you do to improve sensitivity to slow flow? See also Color Plate 1. Ultrasound Physics Review | SPI Edition A. B. C. D. E. 101 Increase wall filter Decrease packet size Decrease color gain Decrease pulse repetition frequency Change color map AIT–SIC item. 454. The packet size in color Doppler refers to the number of: A. B. C. D. E. Pulses per second Sample volumes per scan line Scan lines per unit area Pulse/listen cycles per acoustic scan line Pulses required to create one frame 455. Which of the following is present in this Doppler spectral waveform? See also Color Plate 2. A. B. C. D. E. Spectral broadening Narrow velocity range Aliasing Mirror imaging Range ambiguity 456. While performing a Doppler study, you underestimated the measurement of the Doppler angle of incidence. What error will result from this mistake? A. B. C. D. E. The frequency shift will be underestimated. No Doppler frequency shift will be detected. Mirror imaging of the Doppler spectrum will occur. The velocity estimation will be inaccurate. Aliasing of the Doppler spectrum will occur. Ultrasound Physics Review | SPI Edition 102 The next three questions refer to the following illustration, in which five transducers are imaging a vessel at different incident angles. The arrow indicates the direction of blood flow. 457. Which transducer will detect the largest Doppler frequency shift? A. B. C. D. E. 458. Which transducer would NOT detect a Doppler frequency shift? A. B. C. D. E. 459. Which transducer would demonstrate a waveform ABOVE the zero baseline? A. B. C. D. E. All except for E 460. A commonly used process for determining direction in a Doppler instrument is: A. Zero-crossing detection B. Autocorrelation C. Phase quadrature detection Ultrasound Physics Review | SPI Edition 103 D. Range gating E. Spectral analysis 461. What method is used to steer the color beam with a linear array transducer? A. B. C. D. E. Mechanical Electronic time delays Electronic voltage variation Apodization The color beam cannot be steered with a linear array transducer. 462. When color Doppler is activated, in order to maintain frame rate, what may be reduced in the underlying B-mode image? A. B. C. D. E. The number of focal zones The scan line density The frame averaging (persistence) A and B B and C 463. What Doppler technique does NOT provide range resolution? A. B. C. D. E. Color Doppler Power Doppler Pulsed-wave Doppler Continuous-wave Doppler No Doppler technique can provide range resolution. 464. You have obtained a color Doppler image of the common carotid artery. If the received ultrasound frequency is greater than the transmitted ultrasound frequency, which of the following would be correct? A. B. C. D. E. Color encoding red, negative Doppler shift Color encoding blue, negative Doppler shift Color encoding red, positive Doppler shift Color encoding blue, positive Doppler shift No Doppler shift was detected. 465. Aliasing is a potential problem in PW Doppler because of: A. B. C. D. The use of high pulse repetition frequencies The Doppler signal being sampled rather than recorded continuously Dynamic focusing The motion of the interface perpendicular to ultrasound wave propagation E. Perpendicular incidence 466. What does the Doppler signal spectral display depict? Ultrasound Physics Review | SPI Edition A. B. C. D. E. 104 Relative signal power at each frequency in the Doppler signal Depth to each vessel Volume flow rate Transmit frequency Acoustic power 467. Increasing the wall filter during Doppler sampling will: A. B. C. D. E. Increase visibility of low-velocity signals Increase spectral broadening Decrease bandwidth Reduce display of low frequency shifts Reduce aliasing AIT–SIC item. 468. What would be the most likely result from increasing the transmit frequency of the color Doppler? A. B. C. D. E. Improved sensitivity to slow flow Improved penetration for imaging flow in deep tissues Reduced flash artifact obscuring small vessel flow Reduced color Doppler aliasing Improved visibility of complex flow hemodynamics AIT–SIC item. 469. What would be the most likely result from lowering the color threshold? A. B. C. D. E. Increased visibility of small vessel flow in a parenchymal organ Decreased flash artifact Increased color writing on the vessel or cardiac wall Increased frame rate Improved color penetration AIT–SIC item. 470. What method is most commonly used to perform spectral analysis for pulsed Doppler? A. B. C. D. E. Zero-crossing detection Fourier analysis Reynolds number Cross correlation Autocorrelation 471. During Doppler interrogation of the carotid artery, you detect spectral mirroring. Which of the following is a common cause of this artifact? A. Doppler angle of interrogation near 90° B. Doppler angle of interrogation near 0° Ultrasound Physics Review | SPI Edition 105 C. Wall filter set too high D. PRF set too low E. Doppler gain set too low AIT–SIC item. The next two questions refer to the following image: 472. This Doppler waveform can be most accurately described as exhibiting: A. B. C. D. E. Aliasing Spectral broadening Mirror-image artifact Bidirectional flow Saturation 473. What system control should be adjusted to optimize this waveform? A. B. C. D. E. Wall filter Packet size Gain Pulse repetition frequency Sample volume size AIT–SIC item. 474. What Doppler control should be adjusted to optimize this Doppler spectral waveform? A. B. C. D. Wall filter Packet size Gain Pulse repetition frequency Ultrasound Physics Review | SPI Edition 106 E. Baseline AIT–SIC item. 475. The Doppler frequency shift is defined as: A. The difference between the Doppler frequency and the imaging frequency B. The difference between the transmitted and received frequencies C. The time between the transmitted and received pulses D. The rate at which the transducer emits pulses E. The amplitude of the transmitted Doppler signal 476. According to the Doppler equation, which of the following is NOT true? A. Increasing Doppler frequency will increase the frequency shift. B. Increasing the Doppler interrogation angle will increase the frequency shift. C. Decreasing the reflector speed will decrease the frequency shift. D. No frequency shift is detected when the Doppler beam strikes the reflector with perpendicular incidence. E. Velocity information can be obtained from the frequency shift if the angle of incidence is known. 477. The Nyquist limit describes which of the following? A. Penetration limit of pulsed-wave Doppler B. Transit time of pulsed-wave Doppler C. Sampling frequency needed for detecting the Doppler signal unambiguously D. Sampling method used for continuous-wave Doppler E. Method used for determining directional information in a Doppler-shifted signal 478. What information does the z-axis (brightness) on the Doppler spectrum provide? A. B. C. D. E. Velocity Velocity range Bandwidth Amplitude Frequency shift 479. A waveform from the internal carotid artery obtained at a Doppler angle of 45° shows aliasing. Which of the following choices will help you unwrap this waveform? A. Decrease the angle of incidence. B. Decrease the high pass filter. Ultrasound Physics Review | SPI Edition 107 C. Raise the zero baseline. D. Increase the pulse repetition frequency. E. Increase the Doppler frequency. 480. While performing a color Doppler exam in the abdomen you have adjusted several system controls and notice that the frame rate has decreased. Which of the following adjustments can you make to improve the color frame rate? A. B. C. D. E. Increase the packet size Decrease the pulse repetition frequency Decrease the color box width Increase the scan line density Increase the wall filter 481. You are performing a carotid duplex examination with the following parameters: 5 MHz Doppler frequency, 6 kHz PRF, 4 cm depth, and 1.5 mm sample volume length. What is the aliasing frequency? A. B. C. D. E. 5 MHz 6 kHz 12 kHz 1.5 MHz 3 kHz 482. The rapid technique used in most color Doppler systems to obtain the mean Doppler frequency shift is: A. B. C. D. E. Fast Fourier transform Phase quadrature Autocorrelation Zero-crossing detector Variance 483. What information is colorized in an image using power Doppler? A. B. C. D. E. Frequency shift Flow velocity Doppler signal amplitude Frequency bandwidth Acoustic power 484. In the following waveform, the end-diastolic flow velocity cannot be measured. What control adjustment should be performed to obtain this measurement? Ultrasound Physics Review | SPI Edition A. B. C. D. E. 108 Increase the pulse repetition frequency Decrease the angle of incidence Lower the zero baseline Increase the Doppler gain Lower the wall filter AIT–SIC item. 485. You have encountered spectral broadening of the internal carotid artery waveform. This most likely indicates: A. B. C. D. E. Slow heart rate Tachycardia Accelerated flow Turbulent flow High-resistance flow 486. What flow characteristic is depicted in this illustration? Flow A. B. C. D. E. Turbulent flow Blunt flow profile Flat flow profile Stenotic flow profile Parabolic flow profile 487. What term describes the number of pulses that are used to determine the velocity along a color line of sight? A. B. C. D. E. Color gate Packet size Pulse repetition frequency Pulse duration Pulse repetition period 488. What display method will help you to demonstrate flow turbulence with color Doppler? Ultrasound Physics Review | SPI Edition A. B. C. D. E. 109 Autocorrelation Variance Fast Fourier analysis Zero-crossing detection Phase quadrature detection 489. What term would describe a Doppler waveform obtained at location “C” in this depiction of an arterial stenosis? A. A. B. C. D. E. B. C. Parabolic flow profile Laminar flow profile Plug flow profile Spectral broadening flow profile Dampened flow profile 490. What parameter describes the axial length of the sampling volume for a color pixel? A. B. C. D. E. Color sample gate Packet size Pulse repetition frequency Pulse repetition period Line density 491. What type of Doppler device uses two elements, one to receive and one to transmit? A. B. C. D. E. Power Doppler Color Doppler Continuous-wave Doppler Pulsed-wave Doppler All of the above 492. Spectral analysis is used to: A. Determine the distribution and magnitude of frequency shifts in the reflected Doppler signal. B. Eliminate aliasing from the reflected signal. C. Color-encode the Doppler frequency shift. D. Eliminate low-frequency shifts from the display. Ultrasound Physics Review | SPI Edition 110 E. Determine the velocity of the moving reflector. 493. Color flash artifact is obscuring the anatomy of interest in an exam of the abdominal aorta. What can you do to reduce impact of the flash? A. B. C. D. E. Increase the color gain Decrease the pulse repetition frequency Increase the wall filter Increase the packet size Increase the Doppler transmit frequency AIT–SIC item. 494. While evaluating the liver vasculature with color Doppler, you are unable to obtain signals from the deeper vessels. What should you do to enhance your ability to demonstrate deep flow? A. B. C. D. E. Decrease the packet size Increase the scan line density Increase the wall filter Increase the pulse repetition frequency Decrease the ultrasound frequency AIT–SIC item. 495. Loss of fluid energy through inertia: A. B. C. D. E. Is greatest during steady flow through a rigid tube of constant caliber Is best described by Poiseuille’s law Is greatest in a tortuous vessel with multiple obstructions Accounts for less energy loss than viscous losses Is greatest with high flow speeds in a large tube 496. Which of the following statements about turbulent flow is NOT true? A. B. C. D. E. It can be predicted by the Reynolds number. It is responsible for murmurs, bruits, and thrills. It causes an increase in pressure downstream. It occurs where there are abrupt variations in vessel diameter. It is affected by velocity. 497. Which of the following statements most correctly describes the occurrence of diastolic flow reversal in the arterial system? A. It is always an abnormal finding. B. It is seen in and proximal to high-resistance vessels. C. It is most commonly observed in vessels that supply low-resistance beds. D. It can be enhanced by body heating. E. It is found in the internal carotid artery. Ultrasound Physics Review | SPI Edition 195 Grating lobes are the same as side lobes but occur with array transducers. These lobes are the result of sound energy traveling from the transducer array in a direction different from that of the main beam. They generally are much weaker than the main beam and do not produce tissue reflections with enough strength to be displayed. But in some cases they may strike a strong reflector or be strong enough to cause artifactual echoes in the image. They are most easily seen when imaging fluid because of the decreased attenuation and increased visibility of artifacts. 448. A. Dynamic receive focusing. 449. E. Tissue harmonic imaging. In tissue harmonic imaging, the receiver selectively “listens” to the harmonic frequencies that are generated as the sound travels through the tissue. The second harmonic is the strongest harmonic produced. This is twice the transmitted frequency. 450. A. One. DOPPLER INSTRUMENTATION AND HEMODYNAMICS 451. E. None of the above. CW (continuous-wave) Doppler does not have an imposed maximum velocity limit like PW (pulsed-wave) Doppler. In fact, CW Doppler may be used in instances where accurate velocities cannot be obtained with PW Doppler. 452. D. One-half the pulse repetition frequency. Aliasing of the Doppler spectrum is an artifact that occurs with PW Doppler when the frequency shift is greater than half the Doppler PRF. 453. D. Decrease pulse repetition frequency. When slow flow is present, the color Doppler system must be sensitized to detect low frequency shifts (slow flow produces low frequency shifts). Setting PRF lower increases sensitivity to low frequency shifts. At low PRFs there is more time between the pulses, which allows time for the slow-moving blood flow to move and be detected by the system. Other methods of improving sensitivity to slow flow include decreasing the wall filter and increasing the Doppler frequency. 454. D. Pulse/listen cycles per acoustic scan line. Ultrasound Physics Review | SPI Edition 196 For color Doppler, each line of sight must be pulsed multiple times. The number of pulses per line is termed ensemble length, packet size, or shots per line. The number of pulses transmitted in one second is the pulse repetition frequency (PRF). The number of those pulses fired on each scan line is the ensemble length. 455. A. Spectral broadening. The waveform shows fill-in of the spectral window. This loss of the window is indicative of spectral broadening. Spectral broadening is associated with turbulent flow. 456. D. The velocity estimation will be inaccurate. The velocity estimation in Doppler ultrasound is based on measurement of the Doppler angle of incidence—the angle at which the Doppler beam intersects the blood flow. Because the blood flow is not directly visualized, the Doppler angle-correction cursor is aligned parallel to the walls of the vessel at the point of sampling. If this measurement is underestimated, the velocity of the flow will be underestimated. If this measurement is overestimated, the velocity of flow will be overestimated. Any time the angle-correction cursor is not adjusted parallel to the wall, the velocity estimation is in error. 457. A. A The transducer labeled A is firing its beam at a 0° angle to flow. For any given velocity of flow, the maximum frequency shift will be obtained at 0°. 458. E. E The transducer labeled E is firing its beam at a 90° angle to flow. The Doppler equation tells us that we cannot detect a frequency shift at an incident angle of 90°. 459. E. All except for E. 460. C. Phase quadrature detection. 461. B. Electronic time delays. A linear array transducer steers the beam for color Doppler in the same way a phased array transducer steers its beam—electronically. The active elements are fired with very slight time delays, causing the beam to veer off at an angle from the transducer face. 462. D. A and B. Ultrasound Physics Review | SPI Edition 197 To maintain an adequate frame rate in color Doppler, the B-mode image is compromised by reducing the number of focal zones to 1 or 2 and by reducing the scan line density, which results in lower lateral resolution. 463. D. Continuous-wave Doppler. Range resolution is the ability to determine the depth from which an echo has arrived. For range resolution, the sound must be pulsed so that the echo arrival time from each pulse can be measured. Once the arrival time of the echo is known, the distance to the reflector can be determined. This works because we know the speed of sound in tissue and assume it to be constant. 464. C. Color encoding red, positive Doppler shift. When the Doppler ultrasound beam intersects a vessel in which the blood is flowing toward the Doppler beam, the frequency of the reflected signal is higher than that of the transmitted signal. This is termed a positive frequency shift. All Doppler systems are set up so that positive Doppler shifts are color-encoded red and negative Doppler shifts are colorencoded blue. The specific color map in use determines the shading of red and blue and the colors in between. An Invert function is available on most systems that allows the user to reverse the color designation. 465. B. The Doppler signal being sampled rather than recorded continuously. Aliasing occurs because the frequency-shifted signal is not adequately sampled. The sampling rate is set by the system pulse repetition frequency (PRF). If the frequency shift exceeds half the PRF, aliasing of the signal will occur. 466. A. Relative signal power at each frequency in the Doppler signal. The Doppler signal spectral display depicts the frequency bandwidth and range of amplitudes in the reflected signal. The amplitude or signal power depends on the relative number of red blood cells comprising each component of the frequency-shift spectrum. 467. D. Reduce display of low frequency shifts. The wall filter (also known as high pass filter) is used to eliminate frequency shifts below a set threshold from the display. If the filter is set at 50 Hz, then any frequency shift of 50 Hz or less will not be displayed. Increasing the wall filter helps to eliminate the high-amplitude, low– frequency shift signals caused by movement of the vessel wall. Nevertheless, it must be kept in mind that low frequency shifts may also be a result of slow flow. So any time the wall filter is increased, the system is less sensitive to slow flow. Ultrasound Physics Review | SPI Edition 198 468. A. Improved sensitivity to slow flow. Increasing the color Doppler transmit frequency will result in larger frequency shifts from slow flow and thus improved visibility. It will decrease penetration to flow in vessels deep within the tissues. Changing the ultrasound frequency has a negligible effect on frame rate, flash artifact, or visualization of complex flow hemodynamics. Although one could argue that the increased frequency shifts from slow-moving tissue would be more visible with higher frequencies and may result in increased flash artifact, increased visibility of slow flow is still the best answer to this question. 469. C. Increased color writing on the vessel or cardiac wall. The threshold controls the brightness of the shade of gray that the color is allowed to overwrite. If the threshold is lowered, it is more likely that the color will overwrite the vessel or cardiac wall. Axial resolution in color Doppler almost always is poorer than that in B-mode. 470. B. Fourier analysis. 471. A. Doppler angle of interrogation near 90°. At a 90° Doppler angle, flow direction cannot be determined and the waveform will be seen on both sides of the baseline. 472. A. Aliasing. With an aliased signal, the peak of the waveform is clipped off and appears on the opposite side of the baseline. It starts from the bottom of the image and points up toward the baseline. It does not start from the baseline and point down. That would indicate retrograde flow. 473. D. Pulse repetition frequency. Because aliasing occurs when the frequency shift exceeds half the PRF, the frequency at which aliasing occurs increases as the PRF increases. Depending on the ultrasound system, the PRF control may be called Velocity Scale, Velocity Range, Flow Rate, or other terms. Whatever it is called, it controls PRF. 474. C. Gain. The gain should be reduced. There is noise in the background behind the spectrum and within the spectral window because the gain is set too high. Changing the sample volume would not affect the background noise, nor would changing the wall filter setting. 475. B. The difference between the transmitted and received frequencies. Ultrasound Physics Review | SPI Edition 199 The Doppler effect causes the transmitted Doppler frequency to be altered when it encounters a moving reflector. The frequency is increased if the reflector is moving toward the beam and decreased if the reflector is moving away from the beam. The difference that occurs between the transmitted frequency and the altered frequency that is reflected back is known as the frequency shift. 476. B. Increasing the Doppler interrogation angle will increase the frequency shift. The Doppler equation is: Δf = 2FV(cos θ) ÷ C where ΔF represents the frequency shift, cosθ represents the Doppler angle of incidence, F represents the Doppler frequency, and C represents sound propagation speed. From this equation we can see that the value for the frequency shift will increase if the velocity of the reflector (the red blood cell) increases. Also, if the Doppler frequency increases, the frequency shift will increase. The cosine value of the Doppler angle of incidence (represented by θ, the Greek letter theta) is used in the equation. This tells us that the smaller the angle, the larger the frequency shift obtained for any given velocity. 477. C. Sampling frequency needed for detecting the Doppler signal unambiguously. 478. D. Amplitude. The z-axis on the Doppler spectrum is represented by the brightness of the dot. The brighter the dot, the greater the amplitude of the reflected signal. The factor affecting the amplitude is the relative number of RBCs reflecting that particular frequency shift. So by noting the brightness of a specific point on the spectral waveform we can get an idea about how much of the flow is moving at any given velocity at a particular point in time. 479. D. Increase the pulse repetition frequency. Decreasing the angle of incidence would cause a larger frequency shift for any given velocity and increase the odds of aliasing. The high pass filter has no effect on aliasing. To reduce aliasing, the zero baseline should be lowered instead of raised. Increasing the PRF raises the Nyquist limit and will help reduce aliasing (unwrap the waveform). Increasing the Doppler frequency will result in a larger frequency shift for any given velocity and increase the chances of aliasing. Ultrasound Physics Review | SPI Edition 200 480. C. Decrease the color box width. The wider the color box, the more lines of sight that must be fired to create one frame. So decreasing the width of the box will improve the frame rate. Increasing the packet size will increase the frame rate. Decreasing the pulse repetition frequency may or may not affect the frame rate but is more likely to decrease it rather than increase it. Increasing the scan line density will decrease the frame rate. Adjusting the wall filter will not affect the frame rate. 481. E. 3 kHz. The only factor that is useful in determining the point of aliasing (Nyquist limit) is the PRF. Aliasing occurs when the frequency shift exceeds half the PRF. 482. C. Autocorrelation. 483. C. Doppler signal amplitude. Power Doppler colorizes the amplitude of the reflected Doppler signal. This brightness of the colors is related to the number of red blood cells. 484. E. Lower the wall filter. 485. D. Turbulent flow. Distal to a stenosis, flow becomes turbulent, demonstrating many different speeds and directions (although net flow is still in the forward direction). This range of speeds and directions results in the reflection of a wide range of frequency shifts that is termed spectral broadening. As the term implies, it is simply a broadening of the spectrum of frequencies reflected back to the transducer. 486. E. Parabolic flow profile. 487. B. Packet size. The packet size is also known as ensemble length or shots per line. 488. B. Variance. Variance maps have a green shade that is used to indicate turbulence. Although they may be used anywhere in the body, variance maps are used primarily for cardiac scanning. Variance maps should not be confused with rainbow maps, which contain some green adjacent to the blue color. These maps are commonly used in vascular scanning. With rainbow maps, the green does not indicate turbulence but merely helps to differentiate levels of frequency shifts in the negative direction. Ultrasound Physics Review | SPI Edition 201 489. D. Spectral broadening flow profile. 490. A. Color sample gate. 491. C. Continuous-wave Doppler. 492. A. Determine the distribution and magnitude of frequency shifts in the reflected Doppler signal. 493. C. Increase the wall filter. Flash artifact is typically a high-amplitude but low–frequency shift signal. It can be reduced on the display by increasing the wall filter. Of course, this comes at a price. Increasing the wall filter also reduces the sensitivity to the low frequency shifts associated with slow flow. 494. E. Decrease the ultrasound frequency. Lower frequencies have increased penetration compared to higher frequencies. No other answer choice would improve penetration of the color Doppler. 495. C. Is greatest in a tortuous vessel with multiple obstructions. Inertial losses of fluid energy depend upon changes in flow direction and changes in velocity when blood is accelerated or decelerated as in pulsatile flow. Tortuous vessels with multiple obstructions would change the direction as well as the velocity of the blood flow, and this would create the greatest loss of fluid energy through inertia. wPellerito JS, Polak JF: Introduction to Vascular Ultrasonography, 6th edition. St. Louis, MO, Elsevier Saunders, 2012, pp 3–7. 496. C. It causes an increase in pressure downstream. Pressure is reduced distal to a stenosis in turbulent flow. 497. B. It is seen in and proximal to high-resistance vessels. 498. D. 75%. Area percent stenosis and diameter percent stenosis are not equal. A 50% diameter stenosis is approximately equal to a 75% area stenosis and a 75% diameter stenosis is approximately equal to a 90% area stenosis. 499. E. A and B.