7/29/2017

Purpose
• Outline a QA program that is
Diagnostic Ultrasound Imaging Quality  Responsive to clinical US lab accrediting bodies, ACR and AIUM
Assurance  Effective at detecting some important system flaws
 Can be carried out effectively by medical physicists

James A. Zagzebski1, Ph.D. • Discuss advanced tools that may enhance or even serve
as an alternative to methods that will be discussed
Zheng Feng Lu2, Ph.D.  UltraIQ analysis software for phantom images
1Dept. of Medical Physics University of Wisconsin, Madison  Aureon transducer tester
2Dept. Of Radiology, University of Chicago, Chicago
• Introduce Doppler tests (currently not required by ACR)

Information on US QA Information From US Accreditation Bodies

• Goodsitt M M et al 1998 Real-time B-mode ultrasound quality control test
procedures. Report of AAPM Ultrasound Task Group No. 1 Med. Phys. 25 1385 • Ultrasound Accreditation Program Requirements, Am
• IEC 61391-1 (2006) Ultrasonics – Pulse-echo scanners – Part 1: Techniques for College of Radiology, (3/22/17 rev)
calibrating spatial measurement systems and measurement system psf response [Link]
• IEC 61391-2 (2010) Ultrasonics– Pulse-echo scanners – Part 2: Measurement of [Link]?la=en
maximum depth of penetration and local dynamic range (1996) • ACR-AAPM Technical Standard for Diagnostic Medical
• IEC 62736 Ultrasonics (2016) – Pulse-echo scanners – Simple methods for Physics Performance Monitoring of Real Time Ultrasound
periodic testing to verify stability of an imaging system’s elementary
performance Equipment. (2016)
[Link]
• AIUM 2014, AIUM Quality Assurance Manual for Gray Scale US Scanners.
• King et al, Evaluation of a low cost liquid ultrasound test object for detection of • AIUM 1998, American Institute of Ultrasound in Medicine,
transducer artefacts. Phys. Med. Biol. 55 (2010) N557-570. Routine Quality Assurance for Diagnostic Ultrasound
• Hangiandreou NJ et al, Four-year experience with a clinical ultrasound Equipment. [Link]
quality control program. Ultrasound in Med. & Biol. 37: 1350-57, 2011.

Annual Surveys, Routine QA (ACR) Physical and Mechanical Inspection, ACR

• Acceptance testing, 6-month Routine QC: optional  Console
• Annual surveys: required  Air filters
 Physical and and mechanical inspection; sterility  Lights, indicators
 Image display performance  Wheels, wheel locks
 Image Uniformity  Proper cleaning (are procedures in place?)
 Viewing monitor, keyboard clean
• Element “dropout” and other sources on non-uniformity
 Other safety issues
 System sensitivity and/or penetration capability
 Geometric measurement accuracy during program initiation (optional
for annual survey)
 Contrast resolution, spatial resolution: optional items for annual
Air filters
survey. [Link]

Before After

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Image Display (Scanner and PACS) Image Display (Scanner and PACS)
[Link]
• Important for monitor on machine • Gain and sensitivity adjustments done
to be set up properly to view all using system monitor
echo levels available and entire • Intrepretation most often done on a
gray bar pattern. PACS workstation.
 Set up during acceptance testing • Important that there is agreement
between image features viewable on
 Take steps to avoid casual PACS and the features seen on the
adjustments (mark or inscribe system monitor.
contrast and brightness controls)
• We were finding that the 15 gray bar
• Most machines provide one or pattern built into the machine was not
more gray scale test patterns for sensitive enough to subtle, but important
setup and for routine QC. faults in monitor agreement.
 are all gray bars visible? (System,
Gray bar on GE Logiq 9
PACS) 10

System Worksheet, page 2 of Report for

SMPTE, TG18 or Other Gray Scale Test Pattern each scanner Monitor agreementGenerate
(cont.)
Save
a gray bar pattern.
it to PACS.
• Available on most Number of gray levels
General Machine Cleanliness:

scanners
Keyboard and knobs clean?
Monitors Clean?
☒Yes
☒Yes
☐No
☐No
seen on the system
Air Filters clean? ☐Yes ☒No
monitor 15+
• 0% to 100% gray Mechanical and Electrical: Number of gray levels
bar pattern Wheels fastened securely and rotate easily?
Wheel locks work well?
☒Yes
☒Yes
☐No
☐No seen on the PACS 15+
Accessories fixed securely? ☒Yes ☐No

• Squares for Cords attached securely? ☒Yes ☐No SMPTE Pattern: 0-5%
detecting geometric
PACS Workstation-System Monitor
Contrast and Brightness between scanner and workstation:
transition:
distortion
☐1 poor ☐2 ☐3 average ☒4 ☐5 excellent
system monitor: NO
Assessment made from Both 1 & 2 below:
Generate a gray bar pattern. Save it to PACS. PACS monitor: YES
• Are all gray Number of gray levels seen on the system monitor 15+
Number of gray levels seen on the PACS 15+ SMPTE Pattern: 95-100%
*Gray bar visualization:
transitions visible? With “patient” registered, push “exam utilities;” push “test pattern.”
Record an image and compare to the workstation
transition:
• Is the 0-5%
Count the number of gray levels seen in the room and on the PACS monitor.
SMPTE Pattern: 0-5% transition: seen on system monitor: NO seen on PACS: YES system monitor: YES
95-100% transition: seen on system monitor: YES seen on PACS: YES

transition visible? PACS monitor: YES

For low level echo detectability, do probes ‘Depth of Penetration’ results judged on the system monitor agree
what you would have chosen if judging on PACS?

• Is the 95-100%
TG18: Q=0+14 Q=128+14 Q=255-14
☒Yes

transition visible? l=1 l=129 l=254

Routine QA: Transducers Tests using phantoms. Current materials:

 Check all transducers on the system  Water-based gels
 (most facilities have many interchangeable probes that float among
systems; a systematic approach to evaluate all probes should be in place.
 Advantages:
 Transducer Inspection Delaminations  Speed of sound = 1540 m/s
 Frayed cables
 Attenuation ~ proportional to frequency
 Proper cleaning (specific attenuation expressed as 0.5
or 0.7 dB/cm-MHz)
 Backscatter
 Disadvantages:
 Subject to desiccation (?)
 Must be kept in containers
 Requires scanning window
[Link]

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Tests using phantoms. Current materials: Phantom test 1: Image Uniformity

• Solid, non-water-based materials - Done with each transducer
(urethane) - This example is not a transducer fault, but a TGC problem
• Advantages:
 Not subject to desiccation
 No need for scanning window;
possibility for soft, deformable
scanning window
 Produce tissue-like backscatter
 Disadvantages:
 C= 1430-1450 m/s
 Attenuation ~ proportional to f1.6
 Surface easily damaged if not
cleaned regularly to remove gels 20

Image Uniformity Non-Uniformity caused by element dropout

 Considered to be the
 Most frequent fault
most important and
seen in QA testing
useful test!
 Image a phantom
 Ideally:
using good coupling
 No loss of sensitivity near
edges of the image  Search for
 No discontinuities between “shadows”
tx focal zones
emanating from the
 No evidence of element
dropout
transducer
 No vertical ‘shadows’  Common in new and
old probes!
20

Need Proper Technique to Detect Element Dropout Difficulties with Uniformity

Transducer with moderate element dropout
• Visualizing 1-2 element dropouts
Spatial compounding disabled
• Use persistence; translate transducer.
Disable spatial
compounding
cross-beam
Sono-CT
Sea Clear

Use single,
shallow transmit
focus

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Objective Criteria being developed Image Uniformity(Automated QC Software)

• IEC 62736 Ultrasonics (2016) – Pulse-echo scanners – Simple methods for
periodic testing to verify stability of an imaging system’s elementary
performance
• AAPM Ultrasound Subcommittee Task Group
• Record a cine loop while translating the transducer to the image plane.
• Compute the ‘median’ image for this (~100) image loop
• Plot a lateral intensity profile from a ~3-10 mm axial range

Median
image
Median Image

Dip magnitude and width analyzed

• A dip >3dB and more than 2 elements wide is worth counting as a defect of in uniformity assessment
possible concern.

Difficulties with Uniformity (coupling) Difficulties with Uniformity (coupling)

• Solution 1: rock transducer from side to side • Solution 2: Use a liquid or easily deformable TM material

Liquid Conventional
King et al, Evaluation of a low-cost liquid
Electronic Probe test
ultrasound test object for detection of transducer
artifacts. Phys. Med. Biol. 55 (2010) N557-570.

30

Difficulties with Uniformity (coupling) Difficulties with Uniformity (coupling)

• Solution 3: Use a phantom having concave windows • Solution 3: Use a phantom having concave windows
(Goodsitt et al, AAPM Ultrasound Task Group work)

(AIUM 2014, AIUM Quality Assurance Manual for Gray

Scale Ultrasound Scanners, manufactured by Ernest
Madsen, Univ. of Wisc.)
Gammex 410

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Transducer worksheet part of UW Report Aureon by ACERTARA

Instructions, uniformity ratings (UW-Madison, not other groups, such as AAPM): [Link]

1=uniform Device to test ultrasound

2=minor inhomogeneity (no more than 2 minor dips) transducers
3=Significant inhomogeneities; transducer is functional, but consider replacing • 2D matrix receiver captures energy
4=Immediate repair or replacement recommended
Data table (1 line for each transducer) profile of transducer while running
Cables/ Uniformity, Sensitivity (Depth of Geometric Accuracy on the scanner system
Transducer
ID/Serial
cracks/
delaminate
dropout Penetration)
(MHz/cm)
H: cm/actual cm
V: cm/actual cm Conclusions and • All 1-D and 2-D transducers from
Number
OK No OK No
recommendations
any manufacturer
Uniformity Rating 1 • All operating modes, including
C1-5
79635YP9 5MHz/13.71cm
H: 5.81/6
DOP ≈ to previous results
☒ Yes ☐ No
ARFI and shear wave imaging
• Assesses lens stability over time
☒ ☐ ☒ ☐
V: 8.01/8 Click here to enter
H5MHz/10.6 cm
• Potential to calculate acoustic dose
comments.

Sensitivity, Maximum Depth of Penetration Maximum “Relative” Depth of Penetration

• Considered by many as a good overall How far can you see the speckle pattern in the material?
check of the integrity of the system
• FOV at 18 cm (or set to match the
phantom/transducer capabilities)
• Output power (MI) at max
• Transmit focus at deepest settings
• Gains, TGC for visualization to the
maximum distance possible

40

Objective Maximum Depth of Visualization IEC Standard 61391-2: Automated Method

• Shi, Al-Sadah, Mackie, Zagzebski, Signal to Noise Ratio Estimates on 1. Record a 2. Record an 3. Average ROI Data
Ultrasound Depth of Penetration (abstract only), Medical Physics 30: 11367, phantom in-air “noise” Horizontally
2003. image image in Both Images
• Gorny, Tradup, Bernatz, Stekel, and Hangiandreou, “Evaluation of an
Automated Depth of Penetration Measurement for the Purpose of Ultrasonic
Scanner Comparison”, (abstract only), J. Ultrasound Med 23: S76, 2004.
• Rubert, et al, Automated Depth of Penetration Measurements for Quality
MPV’
Assurance in Ultrasound (Abstract only), Medical Physics 342, 11367, 2015.
• Specified in IEC International Standards 61391-2 (2010) and 62736
(“Maximum Relative Depth of Penetration” in 62736)
• Compute mean pixel value vs. depth for
phantom (signal+noise) and for noise only (noise)
• Depth where (signal+noise)/noise = 1.4 =DOP

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DOP testing: manual and automated UW Report Transducer worksheet (page 3)

Phantom In-Air Instructions, uniformity ratings (UW-Madison, not other groups, such as AAPM):
1=uniform
2=minor inhomogeneity (no more than 2 minor dips)
Average Pixel Value 3=Significant inhomogeneities; transducer is functional, but consider replacing
4=Immediate repair or replacement recommended
Signal + noise Data table (1 line for each transducer)
in phantom Cables/ Uniformity, Sensitivity (Depth of Geometric Accuracy
Transducer cracks/ dropout Penetration) H: cm/actual cm
ID/Serial delaminate (MHz/cm) V: cm/actual cm Conclusions and
Number recommendations
OK No OK No
1.4 × noise in air
Uniformity Rating 1
C1-5 DOP ≈ to previous results
79635YP9 5MHz/13.71cm
☒ ☐ ☒ ☐
H: 5.81/6 ☒ Yes ☐ No
V: 8.01/8 Click here to enter
H5MHz/10.6 cm
Depth (mm) comments.

Distance Measurement Accuracy: Vertical Distance Measurement Accuracy: Horizontal

 Actual 8.0 cm
 Measure 7.94 cm  Actual 6.0 cm
 error 0.75%  Measure 6.05 cm
 Acceptable  error < .8%
*Action: >1.5mm or 1.5%  Acceptable
*Defect: >2mm 0r 2% *Action: >2mm or 2%
*Defect: >3mm 0r 3%
*Goodsitt M M et al 1998 Real-time B-mode ultrasound quality control test *Goodsitt M M et al 1998 Real-time B-mode ultrasound quality control test
procedures. Report of AAPM Ultrasound Task Group No. 1 Med. Phys. 25 1385
procedures. Report of AAPM Ultrasound Task Group No. 1 Med. Phys. 25 1385

Routine QA (ACR General US Program) Routine QA (ACR General US Program)

• Distance Measurement • Distance Measurement
Accuracy tests Accuracy tests Scan plane is
perpendicular to
 Necessary? (“Scanner is a • Required in the previous views

transducer tied to a computer.”) Acquisition Plane mechanically scanned

Reconstructed Elevational Plane
direction
 May be important for specific (Normal 2-D view)
uses
• Images registered from 3-D
data sets
• Workstation measurements
• Radiation seed implants

49 3-D 2-D

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UW Report Transducer worksheet (page 3)

Routine QA (ACR General US Program)
• Distance Measurement Instructions, uniformity ratings (UW-Madison, not other groups, such as AAPM):
1=uniform
Accuracy tests 2=minor inhomogeneity (no more than 2 minor dips)
• Required in the 3=Significant inhomogeneities; transducer is functional, but consider replacing
mechanically scanned 4=Immediate repair or replacement recommended
Acquisition Plane Reconstructed Elevational Plane
direction (Normal 2-D view) Data table (1 line for each transducer)
Cables/ Uniformity, Sensitivity (Depth of Geometric Accuracy
Transducer cracks/ dropout Penetration) H: cm/actual cm
ID/Serial delaminate (MHz/cm) V: cm/actual cm Conclusions and
Number recommendations
OK No OK No

Uniformity Rating 1
C1-5 DOP ≈ to previous results
79635YP9 5MHz/13.71cm
H: 5.91/6 ☒ Yes ☐ No
Actual: 6.0 cm
☒ ☐ ☒ ☐
V: 8.01/8 Click here to enter
H5MHz/10.6 cm
Measured: 6.04 cm comments.
3-D 2-D Error: <0.7%

Image of a phantom is useful for qualitative

Spatial Resolution? comparisons!
• Not done routinely
 2 image sets, each taken with a
different speed of sound
assumption in the beam former
 Targets not agreed on
universally
• Anechoic objects get fuzzy
with poorer resolution
• Line targets get wider
 Requires standardized gain
settings to make meaningful
 Enhance using computational Conventional Spatial Compounding
methods to measure point
spread function width? Images obtained during routine Breast QC testing, 3/2010

UW Report (page 1, Summary)

4-year Experience with a clinical ultrasound quality
Tests
1. Physical and
Equipment Evaluation
Pass/Fail Comments control program,
Pass
Mechanical Inspection (Hangiandreou et al., Ultrasound Med Biol 37, 1350-1357, 2011)
Machine ID, PACS ID
2. Image Uniformity 6 Probes Pass There is an obvious (small) region of element

Site, Location, Facility and Artifact Survey 0 Probes Fail dropout in the C1-6 transducer. Other transducers
exhibit no apparent dead elements.

UAP* number, Date,

3. Geometric Accuracy 6 Probes Pass
0 Probes Fail

Physicist Evaluation Method # of detected % of detected Recommendation

4. System Sensitivity 6 Probes Pass
0 Probes Fail
5. Scanner Electronic
Image Display Pass
The SMPTE test pattern 0%-5% transition is not “failures” “failures”
seen on the display, but is seen on PACS images.
Performance
6. Primary Mechanical Integrity 47 25.1 Quarterly
All gray level transitions in video test pattern seen; all
Interpretation Display Select one.
transitions on SMPTE pattern also seen.
Performance*
7. Contrast Resolution Enter #. Probes
(Optional) Pass
Enter #. Probes Fail
Image uniformity 124 66.3 Quarterly
☒ Not Tested
8. Spatial Resolution 6 Probes Pass
(Optional) 0 Probes Fail Images of resolution test zones of the phantom are
☐ Not Tested obtained for reference. Distance Accuracy 0 0.0 Annually
Medical Physicist's (or designee's) Recommendations for Quality Improvement:
*ACR Ultrasound The purpose of this program is to: inspect mechanical features and cleanliness of the imaging
system; evaluate adequacies of image monitor settings; inspect transducers and check for DOP (penetration) 3 1.6 Annually, (if done with
Accreditation Program flaws, dead elements, loss of sensitivity; and assess geometric accuracy (calipers); and record
an image for use in assessing consistency of resolution for each probe. During acceptance software)
tests, Doppler also is assessed.

The system is operating well with all probes. The SMPTE test pattern offers an additional,
Clinical Problems 13 7.0 Sonographer’s daily
challenging low level gray transition (0% - 5 %) which often is not easily visualized on the
system monitors, and this is the case for this machine.
inspections
Generally, the system is operating well. TOTAL 187 100.

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Future Gammex
Doppler
Doppler 1425
403
Effect Flow
Flow Phantom
Phantom
in Medical Ultrasound
• Incorporate computational methods for more objective tests
• Expand to other operating modes 32 CM/S
33

 Pulsed Doppler
• Sensitivity (signal to noise at a given depth, for both fast and slow 33 cm/s
flow conditions)
• Velocity accuracy 33 cm/s
Volume Flow rate = 5 ml/s time
Volume Flow rate = 10 ml/s
• Directional Discrimination; gate accuracy, etc. Peak velocity 50.9 cm/s Peak velocity 101.8 cm/s
• Volume flow
• QIBA volume flow project (just starting) With a wedge offset, tilting the
 Color flow transducer to enable a 60o Doppler
 Elasticity, shear wave (SW) imaging angle.
• QIBA work on SW velocity in liver (advanced stages)

Gammex
Doppler
Doppler 1425
403Effect
Flow FlowSiemens
Phantom,
in MedicalPhantomS2000
Ultrasound Gammex 1425
Directional
Doppler Effect FlowDoppler
Accuracy,
in MedicalPhantom
Ultrasound
140 Velocity from Spectral Display vs. Theoretical Velocity

120 32 CM/S
33 32 CM/S
33
Vel from Doppler (cm/s)

100 Series5
Diagonal segment
33 cm/s Series6
Horizontal segment, wedge 33 cm/s
80 Expected (theory)
Series7
33 Series8
cm/s 33 cm/s
60
time .
Series1 time
40
Pulsed flow ContinuousDistance
flow along array (%)
20 System with poor directional detection. Flow
0
appears to be bidirectional, even though it is only
0 20
Theoretical
40 60
Vmax
80
(cm/s)
100 120 140
from right-to left.. Medical Physics Dept.

Gammex
Effects
Doppler 1425
ofEffect
Dead Flowin Phantom
Elements
in Medical Transducers
Ultrasound Summary
• Setting up, maintaining an equipment QA program is straight
32 CM/S
33 forward
• The ACR listed procedures form a useful, basic QA program
33 cm/s Directed by physicist or lab personnel


33 cm/s Integrated effort including lab and technical staff


time  Requires a Phantom

Doppler beam line Doppler beam line  Closely correlates with AIUM list of factors needing to be

emerging from array emerging from area of tested

region with no evidence array exhibiting element • Transducer uniformity problems, element dropout, a frequent
It was recommended
of element dropout. probe(Weaker
dropout. be replaced
spectral fault in today’s scanning machines
Medical Physics Dept.
signal, lower apparent • Computational methods can be developed for objective tests
velocity.)