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Artifacts in diagnostic ultrasound

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Reports in Medical Imaging
11 June 2013
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Ammar Hindi 1 Abstract: Ultrasound artifacts are encountered daily in clinical practice and may be a source
Cynthia Peterson 2 of confusion on interpretation. Some artifacts arise secondary to improper scanning techniques
Richard G Barr 3,4 and may be avoidable. Other artifacts are generated by the physical limitations of the technique.
Recognition of artifacts is important, as they may be clues to tissue composition and aid in
1
Department of Radiology, University
Hospitals of Cleveland, Cleveland, diagnosis. The ability to recognize and correct potential ultrasound artifacts is important for
Ohio, USA; 2Department of Allied image-quality improvement and optimal patient care. In this article, we review common ultra-
Health, Kent State University, Salem,
OH, USA; 3Department of Radiology,
sound artifacts that occur in B mode, spectral and color Doppler, and elastography.
Northeastern Ohio Medical Keywords: artifacts, ultrasound, Doppler artifacts, B-mode artifacts
University, Rootstown, OH, USA;
4
Radiology Consultants, Youngstown,
OH, USA Introduction
Ultrasound (US) artifacts are encountered daily in clinical practice and arise second-
ary to errors inherent to the US beam characteristics, the presence of multiple echo
paths, velocity errors, and attenuation errors. US imaging artifacts are commonly
encountered in clinical US and may be a source of confusion on interpretation. Some
artifacts arise secondary to improper scanning technique and may be avoidable. Other
artifacts are generated by the physical limitations of the technique. Understanding
the physical properties of US, propagation of sound in tissues, and the assumptions
used in image processing allow for a better understanding of US artifacts and why
they arise.1
There are a number of assumptions used to generate US images. These include that
sound travels in a straight line and at a constant speed, the only source of sound is the
transducer, that sound is attenuated uniformly throughout the scan plane, each reflec-
tor in the body will only produce one echo, and the thickness of the slice is assumed
to be infinitely thin. When these assumptions are not accurate, artifacts are produced
that display the tissue scanned inaccurately.
Recognition of artifacts is important, as they may be clues to tissue composition
and aid in diagnosis. The ability to recognize and correct potential US artifacts is
important for image-quality improvement and optimal patient care.
Correspondence: Richard G Barr
Radiology Consultants, Building B,
250 DeBartolo Place, Youngstown,
Gray-scale artifacts
OH 44512, USA Reverberation
Tel +1 330 726 2595
Fax +1 330 726 2349
Appearance
Email rgbarr@zoominternet.net Multiple equidistantly spaced linear reflections (Figure 1).

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Hindi et al Dovepress

A Where it commonly occurs

Trans P
Between two specular reflectors along the US beam path
(eg, in cysts).

Ring-down artifact
Appearance
A line or series of parallel bands extending posterior to a gas
X
collection (Figure 2).

Physics
When the transmitted US beam encounters a small air
20 bubble, the transmitted US energy causes resonant vibra-
B tions ­(resonance) of the air bubbles. These vibrations create

A P

Figure 1 (A) Reverberation artifact in the anterior portion of the urinary bladder
(red arrow). (B) Diagram demonstrating reverberation artifact. The black arrows
represent the sound-wave path as expected. The red arrows demonstrate the
sound waves that reverberate between the two secular reflects. The red arrows can
repeat multiple times. The increased time taken by the reverberations is interpreted
as a similar structure more distal than the real object.

Physics
The US image algorithm assumes that an echo returns to the
transducer after a single reflection and that the depth of an B
object is related to the time for this round trip. In the pres-
ence of two parallel highly reflective surfaces, the echoes
generated from a primary US beam may be repeatedly
reflected back and forth before returning to the transducer for
detection.2,3 When this occurs, multiple echoes are recorded
and displayed. The echo that returns to the transducer after a
single reflection will be displayed in the proper location. The
sequential echoes will take longer to return to the transducer,
and the US processor will erroneously place the delayed
echoes at an increased distance from the transducer. In an
image, this is seen as multiple equidistantly spaced linear
reflections.
Figure 2 (A) In this patient with acute emphysematous cholecystitis, the series of
linear spaced lines (arrows) behind air in the gallbladder wall represents ring-down
artifact. (B) Ring-down artifact arising from gallbladder wall (red arrow) in a patient
Artifact due to with adenomyomatosis. Reverberation of sound in the Rokitansky–Aschoff sinus in
Propagation assumption. this disease process leads to ring-down artifact.

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Dovepress Artifacts in US

a ­continuous sound wave that is transmitted back to the Where it commonly occurs
transducer. This phenomenon is displayed as a line or series Gas bubbles, gallbladder polyps, surgical clips.
of parallel bands extending posterior to a gas collection.
Shadowing
Artifact due to Appearance
Propagation assumption. Dark or hypoechoic band deep to a highly attenuating struc-
ture (Figure 4).
Where it commonly occurs
Posterior to collections of gas (eg, pneumobilia, portal venous
gas, gas in abscesses, bowel).
Physics
When the US beam encounters a tissue that attenuates the
Note sound to a greater or lesser extent than in the surrounding
The banding associated with the comet-tail artifact is not tissue, the strength of the beam distal to this structure will
seen. be either weaker or stronger than in the surrounding field.
Thus, when the US beam encounters a strongly attenuating
Comet-tail artifact or highly reflective structure, the amplitude of the beam distal
Appearance to this structure is diminished. The echoes returning from
Series of multiple, closely spaced small bands of echoes
(Figure 3).

Physics
Comet-tail artifact is a form of reverberation. In this artifact,
the two reflective interfaces and thus sequential echoes are
closely spaced. The sequential echoes may be so close together
that individual signals are not perceivable in the image. The
later echoes may have decreased amplitude secondary to
attenuation; this decreased amplitude is displayed as decreased
width.1,2 The result is an artifact caused by the principle of
reverberation, but with a triangular, tapered shape.

Artifact due to
Propagation assumption.

Figure 4 (A) Clean shadowing (white arrow) behind a large gallstone and dirty
shadowing (black arrow) from an adjacent loop of bowel. (B) The black object
Figure 3 Comet-tail artifact displayed as evenly spaced echogenic bands (red attenuates sound greater than the adjacent grey boxes. The resultant image has a
arrows) beyond a copper intrauterine device. hypoechoic area behind the black object compared to the adjacent areas.

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structures beyond the highly attenuating structure will also Where it commonly occurs
be diminished. The hypoechoic or anechoic band occurring Behind calcifications and stones  ,0.5  mm, behind fat-
deep to a highly attenuating structure is called shadowing. ­containing structures when surrounded by other soft tissues.

Artifact due to Dirty shadowing

Attenuation of sound. Appearance
Low-level echoes in the shadow deep to gas (Figure 4).
Where it commonly occurs
Calcified lesions, dense tumors. Physics
The shadowing that occurs behind gas is due to the high
Clean shadowing degree of reflection at gas/tissue interfaces. Because the
Appearance energy of a sound pulse reflected off gas is essentially the
Uniformly anechoic signal behind a structure (Figure 4). same as the transmitted pulse, the reflected pulse will interact
with the interfaces in front of the gas and produce secondary
Physics reflections that travel back to the gas surface and then reflect
The shadowing (described above) that occurs behind stones, from this surface back to the transducer. These secondary
calcifications, and bones are caused primarily by sound reflections produce low-level echoes in the shadow deep to
attenuation by these structures. Because most of the sound the gas, accounting for the “dirty” appearance.
is absorbed by these structures, much less energy is avail-
able for the generation of secondary reflections, and the Artifact due to
associated shadow tends to be more anechoic and “clean Attenuation of sound.
shadowing.”
Where it commonly occurs
Artifact due to Behind gas collections.
Attenuation of sound.
Increased through-transmission
Where it commonly occurs Appearance
Stones or calcifications .0.5 mm, bones. Hyperechoic area behind a structure (Figure 5).

Partial shadowing Physics

Appearance As sound passes through solid tissues, it is gradually
Hypoechoic signal behind a structure. attenuated. Fluid-containing structures attenuate the sound
much less than solid structures, so the strength of the sound
Physics pulse is greater after passing through fluid than through an
This shadowing (described above) can occur behind highly equivalent amount of solid tissue. Therefore, interfaces
attenuating soft tissues. It also occurs behind calcifica- deep to cystic structures will produce stronger reflections
tions and stones if the cross section of the US beam at the and appear brighter than identical interfaces deep to solid
depth of the stone is greater than the diameter of the stone tissues. In the image, we recognize the increased through-
(approximately ,0.5 mm). By adjusting the focal zone of transmission as a bright band extending from an object of
the transducer at the level of the stone, the greatest focusing low attenuation.
occurs at the level of the stone producing more pronounced This artifact produced by increased through-transmission
shadowing. Because higher-frequency probes can be can be used to distinguish cystic from solid lesions. However,
focused more drastically and because high-frequency sound it is important to realize that solid masses that attenuate sound
is less penetrating, it is usually easier to show shadowing less than adjacent soft tissues may also be associated with
with high-frequency probes. increased through-transmission.

Artifact due to Artifact due to

Attenuation of sound. Attenuation of sound.

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Dovepress Artifacts in US

Figure 5 (A) Increased through-transmission (red arrows) in a breast cyst

demonstrated by the linear increased signals distal to the cyst. (B) The same cyst is
imaged using spatial compounding, which diffuses the artifact (red arrows) due to
the multiple angles of insonation. (C) The schematic C depicts increased through
transmission. There is less attenuation of the sound waves through the cyst leading
to increased returning signals from the tissue behind the cyst.

Where it commonly occurs

Behind fluid-filled structures and occasionally behind solid
lesions that attenuate sound less than surrounding tissue
Figure 6 (A) Transabdominal scan of first-trimester pregnancy with a single
(eg, fibroadenoma). intrauterine gestation. Refraction artifact from the rectus abdominis muscle causes
appearance of a duplicate yolk sac (red arrow) adjacent to the actual yolk sac
(blue arrow). (B) In this schematic depicting refraction, the blue line represents
Note the interface of tissues with different acoustic properties. The red lesion is placed
When using spatial compounding, the through-transmission appropriately in the diagram. The blue lesion is displaced because of the refraction
at the interface.
is diffused over a wedge-shaped area corresponding to the
angles of insonation used in the spatial compounding.
line and thus was reflected from a structure in the direction
Refraction “ghosting” from which it returned. In refraction artifact, echoes return
Appearance from a structure that is located along a path different than
Duplication of a structure or structures appearing wider on that of the returning beam. In other words, a structure that
the US image (Figure 6). is anatomically located lateral to the path of the returning
beam is interpreted by the machine as being located in the
Physics path of the returning beam. Refraction artifact may cause
The speed of sound varies in different tissues. It is structures to appear wider than they actually are or may cause
slowest in adipose tissue (∼1450  m/second), faster an apparent duplication of structures.2
in fluid (∼1480  m/second), and fastest in soft tissues
(∼1540  m/­second). Sound is refracted (changes direction) Artifact due to
when it passes obliquely through an interface between two Propagation assumption.
substances that transmit sound at different speeds. 1 The
degree of this change in direction is dependent on both the Where it most commonly occurs
angle of the incident US beam and the difference in velocity At the interface between the rectus abdominis muscles and
between the two media, as governed by Snell’s law. The US abdominal wall adipose tissue; at the interface between
display assumes that any returning beam travels in a straight liver or spleen and adjacent adipose tissues.

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Refractive shadowing (edge artifact, trap the unwary into thinking there is a defect in the urinary
lateral cystic shadowing) bladder or diaphragm (generally only if there is fluid on
Appearance either side).
Shadow occurring at the edge of a curved surface (Figure 7).
Artifact due to
Physics Propagation assumption.
Because refraction (described above) is also accompanied
by defocusing and loss of beam energy, shadowing may also Where it commonly occurs
occur at the edge of cystic structures.1 Sound waves encoun- Cysts, urinary bladder (appearance of a defect in the bladder
tering a cyst wall or a curved surface at a tangential angle wall), diaphragm if there is fluid on either side (appearance
are scattered and refracted. The result is a lack of echoes of a defect in the diaphragm).
returning from the lateral cyst wall and anything in a direct
path posterior to it. This has an appearance of a linear shadow. Speed propagation
Sound waves encountering a cystic wall or a curved surface Appearance
at a tangential angle are scattered and refracted, leading to Artificial widening of a structure (Figure 8).
energy loss and the formation of a shadow. This artifact may
disappear when changing the angle of the US beam clarifying Physics
the nature of the artifact. Conventionally, US systems form images assuming the speed
One such clinical scenario one should be aware of is upon of sound in tissue is uniform at 1540 m/second.2,3 However,
imaging the urinary bladder. Refractive shadowing may give the speed of sound varies across tissue types and among dif-
a spurious appearance of a defect in the bladder wall. The ferent patients. For example, the speed of sound in muscle is
presence of this artifact can be definitively determined by about 1560–1600 m/second, while the speed of sound in fat
changing the angle of the US beam.3 Occasionally, it will is about 1430–1470 m/second.4 The default assumption of an
incorrect value for the speed of sound leads to broader US
beams, potential calculation inaccuracies, and poorer image
A quality, including degraded point and contrast resolution due
to increased acoustic clutter.5,6
US systems traditionally create images based on the
assumption that the speed of sound travels through all tissues
of the body at a uniform rate of 1540 m/second. US imaging
of the breast or any other tissue without a corrected speed of
sound clearly impacts the resolution of the image (Figure 8B).
Chen and Zagzebski reported that imaging at an incorrect
speed of sound setting not only causes misregistration of the
B position of a point target but also causes the dynamic receive
focus to miss the target.6 This ultimately leads to a significant
decrease in point and lateral contrast resolution. Anderson
et al7 claim that this decreased imaging quality is especially
important in tissue such as the breast, because the distortions
arising from speed-of-sound error are inversely proportional
to the imaging system’s frequency and wavelength. Addition-
ally, Anderson and Trahey8 reported that they expect sound-
speed error would degrade the quality of any image relying on
high spatial and/or contrast resolution, such as the visualiza-
tion of spiculation or capsules, the differentiation of lesions
Figure 7 (A) Edge-effect refractive shadowing emanating from the superior and
inferior edges of the testicle (red arrows). (B) Diagram depicting the cause of and cysts, and US-guided biopsy.7 All of these functions are
refractive shadowing. At the curved surface of the lesion, the ultrasound beam is
deflected. This leads to a rectangular area where no sound waves are returned to
extremely important in clinical sonographic imaging of the
the transducer, leading to an area of shadowing. breast. With the speed of sound corrected, lateral resolution is

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Dovepress Artifacts in US

A improved, as previously discussed, so uncertainties in lateral

measurement are reduced, as illustrated in Figure 8B. We can
assume therefore that measurements in the lateral direction
would better represent the true measurement of the object.
Axially, the measurement accuracy remains unchanged from
that of a conventional system, as the altered speed of sound is
only used in beam-forming calculations and does not affect
the axial measurement scale. It can therefore be postulated
that optimal US images can be generated if a speed-of-sound
B measurement is obtained in individual patients and the speed
PSF Image
then customized to their unique tissue properties. This is
True object not possible at this time. Until this can be performed in real
time, a fixed average corrected value(s) as used in this study
Measurement on previous can be utilized.
images

Artifact due to
Measurement with improved Propagation assumption (incorrect speed of sound).
focus

Where it commonly occurs

C In tissues in which the speed of sound is not near the equip-
ment-set speed of sound (breast if speed-of-sound correction
is not utilized).

Note
Most US phantoms are calibrated to 1540 m/second. If one
uses a speed-of-sound correction (common in breast imaging)
on a phantom, erroneous results will occur.9,10

Side lobes and grating lobe artifacts

Appearance
Hyperechoic rounded object within an anechoic or
hypoechoic structure such as the urinary bladder or gallblad-
der lumen (Figure 9).

6C2-S
H4.0 MHz 170 mm
Pelvic
Figure 8 (A) This pair of images taken in the same location in a patient with Long mid upper General

calcifications in a breast mass was processed using different speed-of-sound 74 dB T1/+1/4/2

assumptions. The image on the left was generated with 1540 m/second as the speed Gain = 4 dB ∆ = 2

of sound, whereas the right image uses a corrected speed of sound for breast tissue. Store in progress
With correction of the speed of sound, calcifications are more discrete and less
artificially elongated. (B) This diagram depicts how the size of an object is affected
by the changes in lateral resolution with different speed-of-sound assumptions. The
measurement on previous images occurs when conventional speed of sound is used
in breast imaging, causing decreased lateral resolution. Measurement with improved
focus occurs when a corrected speed of sound for the tissue is used, improving
lateral resolution. (C) In this patient with a silicone breast implant, the speed of
sound through the silicone is significantly less than in breast tissue. The sound waves
distal to the implant therefore return to the transducer delayed compared to those
through normal breast tissue. The ultrasound system interprets the delay as the
object being deeper in the scan, leading to the apparent disruption of the underlying
muscle (arrow). Figure 9 Side lobe/grating lobe artifact (red arrow) seen in a mucinous ovarian
Abbreviation: PSF, Peak Systolic Velocity. tumor.

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Physics
Every transducer has a main-beam axis along which the
main beams are transmitted parallel to the long axis of the
transducer. In linear array transducers, multiple other low-
amplitude beams project radially at different angles away
from the main-beam axis. These are termed side lobes.
Side lobes occur relatively close to the primary beam, as
opposed to grating lobes that have the same origin, but
are farther removed from the central beam. Side-lobe and
grating lobe beams may be reflected back (from a strong
reflector) to the transducer and sometimes detected. The
transducer/machine cannot differentiate between reflected
beams returning from the main beam versus those return-
ing from off-axis lobes. It considers any detected beam as B
originating from the main axis. Off-axis lobes are lower in
amplitude than the main axis beam, and therefore in order
to be detected by the transducer, they must be reflected by
a highly reflective (ie, highly echogenic) structure. Off-axis
lobe artifacts have the appearance of a hyperechoic object
within an anechoic or hypoechoic structure, such as the
urinary bladder or gallbladder lumen. Also, this artifact
may be seen with needle biopsy when the needle is a strong
reflector.11 Off-axis lobe artifacts can also be seen on color
and spectral Doppler imaging.11

Artifact due to
Propagation.
Figure 10 (A) Volume-averaging artifact demonstrated in a saline breast implant
(red arrow) due to lack of finite thickness of the beam slice. Increased through-
Where it occurs transmission is also demonstrated as increased echogenicity behind the implant.
Urinary bladder, gallbladder, needle biopsy. (B) In this schematic demonstrating volume averaging, the solid lines represent the
ultrasound beam transmitted and the dashed lines represent the received sound
waves. When the focal zone is placed at the depth of the lesions, only the circle is
Volume averaging (section insonated with the transmit beam leading to an image with only the circle. In the
image on the right, the lesions are distal to the focal zone and both the circle and
thickness, slice thickness) square are insonated, leading to the image having received signals from both the
circle and square in the image.
Appearance Abbreviation: TRVS, transverse.
False sludge or debris within anechoic cystic structures
(Figure 10). distal from the focal zone are more prone to artifacts ­resulting
from volume averaging between adjacent objects that both
Physics fall within the thickness of the beam. In other words, the
The thickness of the main US beam as it exits the transducer thicker the image slice, the more likely that two different
is equal to the thickness of the transducer array. The finite adjacent objects will fall within that image slice. This artifact
beam width creates a partial-volume artifact related to slice can be minimized by placing the focal zone at the level of
or section thickness. When the beam includes both a cystic the tissue/structure of interest.12
structure and a solid structure, the scan line consists of echoes
from both the cystic and solid structure. The accumulation Artifact due to
of scan lines of this nature produces filling in of the cystic Propagation assumption.
structure. As the beam propagates away from the transducer,
it narrows gradually until it reaches the focal zone. It then Where it commonly occurs
gradually widens again. Structures that are proximal to and Urinary bladder, gallbladder, and cysts.

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Dovepress Artifacts in US

Range ambiguity
Appearance
Structures deep to the scanning range are depicted in the
image.

Physics
The US system assumes that all received echoes are formed
from the most recent transmitted pulse. A short US pulse is
sent out from the transducer, and the transducer is silent for a
time to receive the returning echoes. All echoes received dur-
ing this sampling period are assigned a depth based on the time
interval between the transmitted pulse and the detected echo.
A second pulse is then sent out, and the transducer is again
silent to receive returning echoes. At high pulse-repetition B
frequency (PRF), echoes from deep structures interrogated by
the first pulse arrive at the transducer after the second pulse
has been transmitted. These echoes are interpreted as having
originated from the most recent transmitted pulse and are
incorrectly placed near the transducer in the image.13

Artifact due to
Improper scanning parameters.
Figure 11 (A) Mirror-image artifact demonstrating the appearance of a hepatic vein
Where it commonly occurs (red arrow) and IVC (dotted arrow) above the diaphragm. (B) Diagram demonstrating
Small parts, endosonography. the cause of the mirror-image artifact. The black arrows are the true path of the
transmitted and received sound waves. The red arrows are how the ultrasound
interprets the sound waves. In the image, the blue object is correctly placed and the
Mirror-image artifact red mirror image occurs on the opposite side of the secular reflector.
Abbreviation: IVC, inferior vena cava.
Appearance
Duplicated structure equidistant from but deep to a strongly that produces a mirror image at the right lung base. A pulse
reflective interface (Figure 11). from the main beam travels through the liver and is reflected
off the diaphragm. This reflected echo reaches the liver lesion
Physics and reflects back to the diaphragm.14 From the diaphragm,
The depth at which each structure is displayed on a US image the echo finally reaches the transducer.12
is proportional to the amount of time it takes for a US beam Because color Doppler scanning creates images with
to return to the transducer from the time when it leaves the marked contrast between vascular structures and soft tissues
transducer. Normally, this amount of time would be primarily (ie, color vs gray scale), mirror-image artifacts are particu-
dependent upon the depth of a tissue from which the beam larly common on color Doppler scans. As with gray-scale
reflects. This would result in an image with an anatomically imaging, color Doppler mirror images occur most frequently
accurate depth. In mirror-image artifact, the return of sound around the lung. However, the increased contrast also allows
beams is delayed, and therefore the structures from which weaker acoustic interfaces, such as bone or even the back wall
these delayed beams are reflected are displayed at a greater of the carotid, to act as mirrors for color Doppler imaging.
depth than their true anatomic depth. This delay occurs
in the presence of highly reflective interfaces, such as the Artifact due to
diaphragm/lung base interface on a right upper quadrant Propagation assumption.
scan. The diaphragm/lung base interface is highly reflec-
tive because gas reflects almost 100% of the sound that Where it commonly occurs
hits it and is therefore the best acoustic mirror in the body.1 Diaphragm with liver lesions or the liver itself being dupli-
The prototypical example is in the setting of a liver lesion cated, trachea.

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Electronic interference/spiking Where it commonly occurs

Appearance With improper time-gain compensation settings, or improper
Bands of noise (Figure 12). focal zone placement.

Physics Speckle
When spurious electronic signals are detected by the US sys- Appearance
tem, bands of noise are displayed in the image. This can occur The random granular texture that obscures anatomy in US
when there is not a dedicated electrical outlet that is appropri- images (noise) (Figure 13).
ately grounded. If a non-dedicated electrical outlet is used and
another piece of equipment is turned on, electric signals may
Physics
Speckle is created by a complex interference of US echoes
enter the US machine, eg, if the US machine is connected to
made by reflectors spaced closer together than the US
an outlet with a respirator and the respirator turns on.
system’s resolution limit. Speckle or acoustic noise occurs
Artifact due to throughout the image. Speckle degrades spatial and contrast
Electronic interference. resolution and obscures the underlying anatomy. Speckle is a
major cause of image degradation in US. Speckle interferes
Where it commonly occurs with the ability of a US system to detect low-contrast objects.
Use of a non-dedicated electrical outlet. Speckle can be reduced using techniques that reduce noise
(ie, higher-frequency transducer, real-time compounding,
Banding adaptive post-processing, and harmonic imaging).
Appearance
A band of increased brightness. Artifact due to
Propagation assumption.
Physics
The focusing characteristics of the transducer may create Where it commonly occurs
a banding artifact, which is a band of increased brightness Everywhere; speckle is inherent in US images.
caused by greater intensity, usually in the focal zone. This is
more noticeable with systems with fixed transmit focusing
Beam-width artifact
Appearance
and dynamic receive focusing. This artifact can also be cre-
Fine, grainy echoes distributed along the inside of cystic
ated by improper time-gain compensation settings.13
structures whose wall is struck obliquely by the US beam
(Figure 14).
Artifact due to
Improper scanning technique.
Physics
The origin of beam-width artifact is similar to that of side-
lobe artifact. The main US beam exits the transducer at

Figure 13 Speckle or noise is present on all ultrasound images and leads to

degradation of the image. Techniques can be used to decrease speckle and therefore
improve image quality. (A) Fundamental image of an invasive ductal breast cancer.
The same image in (B) uses special compounding and adaptive post-processing to
Figure 12 Electronic interference creating spiking artifact (red arrows). reduce speckle, improving image quality.

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Dovepress Artifacts in US

Physics
The different tissues a US beam encounters attenuate the
beam differently. If the attenuation coefficient for a mate-
rial is great, such as with fat, then the beam may not fully
penetrate the imaging field. In this situation, deep structures
may not be visualized. An appropriate frequency transducer
should be selected to optimize penetration. Attenuation is
also dependent on the frequency of the US. Attenuation
increases with increase in frequency. In soft tissues, the
relationship between attenuation and frequency is linear.
Figure 14 Images of the gallbladder taken with the focus in an appropriate
location (A) and deep in the far field (B). The increased echoes adjacent to the In bone and water, attenuation increases as the square of
gallbladder wall (arrow) are beam-width artifact.
the frequency.3

approximately the same width as the transducer, then nar- Artifact due to
rows as it approaches the focal zone and widens again distal Attenuation of sound.
to the focal zone.1 The distal beam may widen beyond the
actual width of the transducer. A highly reflective object Where it commonly occurs
located within the widened beam may generate detectable High-frequency transducers, in tissues which significantly
echoes.2 The transducer cannot differentiate between echoes, attenuate sound (fat, bone).
whether they originate from within the narrow imaging plane
or originate from a location within the widened beam. The Anisotropy
transducer falsely interprets objects located in the widened Appearance
beam to be located within the narrow beam. This can be Hypoechoic area in a structure that has anisotropy
minimized or eliminated by adjusting the focal zone, such (Figure 16).
that it is placed at the level of the target organ/structure that
is being examined. Physics
When a tendon (highly anisotropic) is imaged perpendicular
Artifact due to to the US beam, a characteristic hyperechoic fibrillar appear-
Propagation assumption. ance is displayed. In structures with anisotropy (having
properties that differ according to the direction of measure-
Where it commonly occurs ment) and when the transducer’s angle of incidence is not
Urinary bladder, gallbladder, and other cystic structures. perpendicular to the structure, fewer returning echoes to
the transducer results in a hypoechoic area. This can occur
Attenuation artifact when the US beam is angled as little as 5° relative to the
Appearance long axis of such a structure. This phenomenon can lead to
Nonvisualization of deep structures (Figure 15). misinterpretation and can be overcome by changing the trans-
ducer position (heel-to-toe movement to make the transducer

Ultrasound beam Ultrasound beam

Tendon Tendon

Figure 16 In the image on the left, the ultrasound beam is perpendicular to the
Figure 15 Images of a liver obtained with a 4 MhZ (A) and 6 MhZ transducer tendon throughout its course. The tendon is uniformly hyperechoic. In the image on
(B) demonstrate the loss of signal in the far field with the higher-frequency the right, the tendon is curved. Where the ultrasound beam is perpendicular to the
transducer, due to the increased attenuation of the tissues with the higher-frequency tendon, the tendon is hyperechoic. Where the ultrasound beam is not perpendicular
transducer. to the tendon, the tendon is hypoechoic.

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perpendicular to structure). The artifactual hypoechoic area Aliasing

of the structure will disappear with perpendicular transducer Appearance
positioning. On waveforms, the high-frequency component is wrapped
around to the negative extreme (Figure 18).
Artifact due to
Anisotropy of structure. Physics
An artifact occurring when the velocity of the sampled object
Where it commonly occurs is too great for the Doppler frequency to be determined by
Tendons, and to a lesser extent muscles, ligaments, and the system. Governed by the Nyquist limit, the blood-flow
nerves. direction appears to be reversed. This artifact occurs when the
Doppler sampling rate (PRF) is less than twice the Doppler
Spectral and color Doppler frequency shift. Aliasing causes the high-frequency compo-
nents to wrap around from the positive extreme of the scale
Mirror image (cross talk)
to the negative extreme or vice versa. The change in color
Appearance
assignment can be distinguished from true flow reversal
Mirror image of the spectral display on the opposite side of
because the change is between light color shades rather than
the baseline (Figure 17).
dark color shades. Aliasing can be diminished or eliminated
by increasing the PRF.11
Physics
Velocity information in spectral and color Doppler is
When a strong sound signal in one direction channel leaks
derived from pulsed sound beams that are used to sample
into another, a mirror image of the spectral display on the
opposite side of the baseline occurs. This is called mirror
image or cross talk. Cross talk distinguishes the condition A FR 15 Hz 60º M2 M3
P1 +19.3

of undesired crossover of transmitted sound waves into the 2D PW

78% 64%

receiving transducer in continuous-wave Doppler. C 56

P low
Res
x WF 60 Hz
SV1.5 mm
M2
6.0 Hz
CF 1.3 cm
80%

Artifact due to 3000 Hz

WF 165 Hz
Med
−19.3
cm/s

Propagation assumption.
4.0

Where it commonly occurs −40

Inv cm/s
Any spectral Doppler waveform in which the Doppler
(receiver) gain is too high. 40

80

3.6 sec

FR 7 HZ 60º M3 M6
RP +77.0

2D PW
RRA DIST
B
63% 20% M2 M3
C 48 WF 60 Hz FR 13Hz
P1 +16.0
P med SV2.0 mm
HGen M3
2.3 MHz 2D
CF 80%
6.9 cm
61% C 56
5500 Hz −77.0 P low
WF 247 Hz x Res
cm/s
High
CF
89%
2500 Hz
11 WF 162 Hz
Med −16.0
240 x cm/s

160

860

cm/s

−80
6.6 sec

Figure 18 (A) Aliasing displayed on a spectral Doppler waveform (red arrow). When
the Nyquist limit is exceeded, the waveform “wraps around,” resulting in an inability
Figure 17 Artifactual display of flow beneath the baseline (arrow) in this image is to measure velocity accurately. (B) Aliasing displayed in color Doppler. Due to the
due to improper Doppler gain setting. Nyquist limit being exceeded, the “wrapping around” of velocity causes the fastest
Abbreviation: RRA DIST, right renal artery distal. flow (centrally in the vessel in laminar flow), displayed as blue in this example.

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Dovepress Artifacts in US

the blood flow in vessels of interest.11 A minimum of two

pulses per cycle of Doppler shift frequency is required to
determine the corresponding velocity.12 When there is an
insufficient sampling rate (PRF) relative to the Doppler
signals generated by moving blood, aliased signals occur,
ie, when the velocity scale is set too low relative to the
velocity of flow in a vessel. On spectral Doppler images,
this manifests as wraparound of the highest flow veloci-
ties into the negative part of the graph.15 On color Doppler
images, this manifests as reversed flow within central areas
of higher laminar velocity. This gives the false appearance
of reversal of flow within the vessel. True reversal of flow
versus spurious reversal from aliasing can be differentiated
on color Doppler as follows: in true flow reversal, the veloc- Figure 19 Tissue vibration (red arrow) in tissues adjacent to common femoral vein
during augmentation. The appearance of flow outside of the vessel is due to signal
ity must gradually decrease (or increase) and pass through detection of tissue movement, rather than motion of actual blood flow.
zero velocity, whereas with aliasing this does not occur. The
point at which the velocity reaches zero manifests on color
a detectable Doppler frequency shift that will be assigned a
Doppler as a black stripe.11 Thus, the absence of the black
color. The vibrational motion is both towards and away from
stripe indicates aliasing. If aliasing persists despite turning
the transducer, resulting in a color-assignment mixture or
up the velocity scale, then the velocity within that vessel is
red and blue.
beyond the limit of that scale. This can be a useful indicator
of abnormally elevated velocities, such as occur distal to an
Artifact due to
arterial stenosis.
Patient factors.
Aliasing can be reduced or eliminated by increasing
the velocity scale (which increases the PRF), increasing
Where it commonly occurs
the Doppler angle (which decreases Doppler shift), chang-
Arteriovenous fistulas and shunts.
ing the baseline setting, or using a lower US frequency
(by manually decreasing the frequency or switching
transducers).11
Twinkle
Appearance
A discrete focus of alternating colors with or without an
Artifact due to
associated-color comet-tail artifact (Figure 20).
Improper settings.

Where it commonly occurs FR 8 Hz M3 M6

RP +15.4

Inappropriate velocity scale (set too low), inappropriate 2D

58% BL long LT
C 48
PRF setting. P med
HGen
CF
60%

Tissue vibration 100 HZ

WF 69 Hz
Med −15.4
Appearance cm/s

Red and blue Doppler signal in perivascular soft tissue

(Figure 19). x

Physics
Tissue-vibration artifact is produced in nonflow areas by
bruits, arteriovenous fistulas, and shunts. Turbulence causes 14

pressure fluctuations in the lumen of the vessel that can

Figure 20 Twinkle artifact (red arrow) behind a stone at the ureterovesicular
produce vibration of the vessel wall and the adjacent soft junction. The stone was not visible on gray-scale ultrasound, and visualization of the
tissues. When the tissue interfaces vibrate, they may produce twinkle artifact made the diagnosing of urolithiasis possible.

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Hindi et al Dovepress

Physics Flash artifact

Twinkle is a phenomenon dependent on US machine settings Appearance
(color-write priority, gray-scale gain, and PRF), motion of the Spurious appearance of blood flow (Figure 21).
object scanned with respect to the transducer, and equipment
used. Presence of this artifact is sometimes beneficial, such
Physics
as in cases of detection of urinary tract stones with indistinct
Vascular motion artifact and flash artifact have similar under-
echogenicity and poor posterior acoustic shadowing. In
lying physical causes. In flash artifact, motion of the patient’s
prenatal fetal scans, it can imitate aberrant vessels or flows
body, motion of the probe, or motion of an anatomic structure
behind echogenic structures or give the impression of cardiac
secondary to an external force (such as the pulsation of an
activity in fetal demise. Because this artifact is dependent on
adjacent artery or the heart) can cause motion of the reflectors
US machine settings it is possible to distinguish it from real
within a structure of interest without the presence of blood
vessels by changing some parameters. For instance, when
flow. The motion of the reflectors results in a Doppler shift,
the focal zone is above the source of the artifact (such as a
giving a spurious appearance of blood flow. Hypoechoic and
urinary stone), the artifact disappears, but when the focal
anechoic structures are more susceptible to flash artifact, and
zone is under the hyperechoic area, it occurs. This could
therefore it is seen more commonly in cysts, the gallbladder,
be an easy distinguishing maneuver in assessment of this
dilated bile ducts, and ascites. This stems from limitations
phenomenon.
of the motion discriminator function that can be found in
When a large number of reflectors (and therefore
most US machines. The motion discriminator functions to
­Doppler shifts) are included in the analysis, the result-
eliminate false flow, but is less effective in doing so in areas
ing phase shift provides a correct estimation of velocity.
of low echogenicity.11
Furthermore, the velocity estimation is unchanged by faint
motion. When the number of reflectors is small (as occurs
Artifact due to
in calcifications), the velocity estimation can be affected
Patient factors.
by any faint motion.16
The twinkling artifact is probably generated through
slight variations in path length of the transmitted and Where it commonly occurs
reflected US. Focusing an US array transducer depends Around the heart, patient motion (breathing, gas
on precise phasing among the elements in the scan-head movement).
array. Even minor phase errors could produce fluctuations
in the US field generated by a transducer. These fluctua- Vascular motion artifact
tions could easily alter the effective beam path slightly Appearance
from firing to firing, although the beam will be pointed in Artifactual increase and decrease of spectral Doppler velocity
the correct direction on average. The same types of errors pattern in a cyclical fashion (Figure 22).
only increase on reception of the reflected wave in which
the same phasing issues also occur. If there is a strong
LOGIQ
reflector with a rough surface, these slight variations in E9
0
beam direction could be magnified to produce apparent
aliased Doppler shifts. Multiple reverberations would
further magnify this effect by projecting the artifact below 21
5

the reflecting surface. The effect is most commonly seen

in urinary stones, and the rougher the surface, the greater
the twinkling artifact.17 −21 10
cm/s

Artifact due to
Noise generated in calcification. 15

IVC long

Where it commonly occurs Figure 21 Flash artifact (arrow) visualized due to motion of bowel gas anterior to
Urinary stones. IVC (inferior vena cava).

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Dovepress Artifacts in US

+19.3 +19.3
PW PW
40% 40%
WF 120 Hz WF 120 Hz
SV7.5 mm SV0.5 mm
M2 M2
6.0 MHz 6.0 MHz
1.8 cm x 1.8 cm
x
−19.3 −19.3
cm/s cm/s

4.0 4.0
−120 −120

−80 −80

−40 −40

Inv Inv
cm/s cm/s

A 3.6 sec
40 B 3.6 sec
40

Figure 23 Spurious spectral broadening visualized in (A) due to large sample

Figure 22 Flow in portal vein seen on both sides of baseline due to vascular motion volume. When sample-volume size is reduced, the accurate depiction of flow
artifact. velocities within the vessel is seen in image (B).

Physics where it is highest, gradually decreasing down to the lowest

Vascular motion artifact can be encountered most often when velocity abutting the vessel wall. In spectral Doppler imag-
interrogating hepatic vessels. Understanding vascular motion ing, increasing the size of the sample volume box (the gate)
artifact depends upon understanding laminar blood flow. In a is helpful in searching for trickle flow or trying to obtain a
blood vessel in which the flow is laminar, there is an organized Doppler signal behind a shadowing calcified plaque. The size
range of velocities from the center of the vessel, where it is high- of the sample volume box is normally kept between 2 and
est, gradually decreasing down to the lowest velocity abutting 3 mm.18 However, if the sample volume box is set too large
the vessel wall. Ideally, the gate should be set to a small size (.3.5 mm), it will include a wider range of the velocities
(2–3 mm), and the spectral Doppler sample should be taken at within the vessel. This manifests on the spectral waveform
the center of the vessel. Cardiac motion induces cyclical motion as spurious spectral broadening. This is spurious because true
of the liver (and of course motion of the hepatic vessels within spectral broadening indicates the presence of turbulent flow,
it). The vessel thus moves in relation to the fixed location of turbulent flow being present just distal to an arterial stenosis.19
the sampling box. This results in sampling of a continuum of A small gate of 1.5–2  mm should be used to obtain good
locations within the cross section of the blood vessel. As the central vessel laminar flow information without including
sample box interrogates toward the periphery and back toward the slower-flowing signals from blood near the vessel wall.19
the center, the spectral Doppler velocity pattern will artifactu- If the gate is too small (,1.5 mm), the Doppler signal may
ally decrease and increase in a cyclical fashion. This appearance be missed. Spurious spectral broadening can also result when
can be falsely interpreted as, eg, a cyclical pattern in a portal the sample volume box is located close to the vessel wall and
vein indicating tricuspid regurgitation.11 when the gain setting is too high. Lastly, it may result when
using a large Doppler angle (close to 90°). Thus, errors can be
Artifact due to minimized by keeping the Doppler angle less than 60°.11
Patient factors.
Artifact due to
Where it commonly occurs Improper scanning technique.
Hepatic vessels.
Where it commonly occurs
Spurious spectral broadening When a wide gate is used; sample box located close to the
Appearance vessel wall; gain setting too high.
Spurious spectral broadening (Figure 23).
Spurious thrombosis related to
Physics velocity scale, wall filter, and gain
In a blood vessel in which the flow is laminar, there is an Appearance
organized range of velocities from the center of the vessel, Spurious thrombosis (Figure 24).

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Hindi et al Dovepress

Artifact due to
FR 7 Hz M3 m6
RP +77.0
Improper scanning technique.
2D
63% RRA
C 48
P med
HGen

CF
Where it commonly occurs
61%
5500 Hz
WF 247 Hz
Veins.
High −77.0
cm/s

x
Directional ambiguity
Appearance
Doppler signal appearing both above and below the spectral
zero-velocity baseline.
11

Physics
Directional ambiguity occurs when the main US beam
Figure 24 Artifactual appearance of thrombosis in IVC (arrow) due to PRF/velocity intercepts a vessel at a 90° angle.11 The sound wave reflected
scale setting being too high to display low-velocity slow venous flow.
Abbreviations: IVC, inferior vena cava; PRF, pulse repitition frequency; RRA, right from flowing blood is neither moving toward nor away from
renal artery. the direction of the wave and does not undergo a Doppler
shift. Without a Doppler shift, the direction of flow cannot
Physics be deduced. In this situation, spectral Doppler information
Spurious thrombosis may be seen as a result of setting the is displayed as a tracing both above and below the spectral
velocity scale or wall filter too high or the gain too low. When zero-velocity baseline.11 This artifact is worsened by higher
the velocity scale is set too high relative to the blood-flow gain settings and is easily corrected when the beam direction
velocity in a slow-flow vessel, visualization of flow in such is shifted to an angle either side of 90°. When obtaining a
a vessel is decreased. Thus, such vessels may falsely appear sample volume in spectral Doppler imaging, one should avoid
thrombosed. the portion of a vessel that intercepts the interrogating beam
When the gain is set too low, some Doppler informa- at 90°; however, the Doppler angle should ideally be kept at
tion is lost, especially in vessels with slow flow. When the less than 60°. Note that electronic angulation, when available,
gain setting is too high, this produces random color noise can also be used to adjust the Doppler angle.11
throughout the display. The color gain should be increased
until noise is encountered, and then decreased until the noise Artifact due to
just clears from the image.11 Improper scanning technique.
A wall filter is a user-adjustable function of the US machine
that allows exclusion of color flow information above or Where it commonly occurs
below specified Doppler frequency levels. A high-pass filter When a Doppler beam is 90° to flowing blood.
includes higher Doppler frequency information (higher veloc-
ity) and excludes Doppler frequency information below the Elastography
user-specified level. A high-pass filter is used when imaging Bull’s eye artifact (strain)
higher-velocity vessels (arteries) and has the effect of remov- Appearance
ing artifacts related to vessel-wall motion, which is typically White central signal within a black outer signal and a bright
a low-frequency signal. Artifacts can arise when there is spot posterior to a lesion (Figure 25).
true slow blood flow in a vessel (which will produce lower-
frequency Doppler shifts). If these Doppler shift frequencies Physics
are below the level set for the filter, then this will produce a A characteristic elastogram is seen with benign simple
spurious appearance of lack of flow in such vessels (spurious and complicated cysts with some systems. This artifact is
thrombosis).11 Diagnostically significant information can also characterized by a white central signal within a black outer
be lost in the measurement of resistive index. Arterial diastolic signal and a bright spot posterior to the lesion.20 This artifact
flow is lower in velocity (producing lower-frequency Doppler has a high predictive value for the lesion being a benign
shifts), and therefore if the low-velocity diastolic flow is filtered simple or complicated cyst. If there is a solid component in
out, this will produce a spuriously high resistive index.11 the cyst, it will appear as a solid lesion within the pattern.

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Dovepress Artifacts in US

Figure 26 B-mode image and elastogram of a lipoma. Note the white ring (red
arrows) surrounding the lesion on the elastogram. This pattern is caused by the
lesion moving in and out of the imaging plane during the elasticity image acquisition
and is called the sliding artifact. Because this artifact usually occurs with lesions that
can move independent of the adjacent tissue, it is usually identified in benign lesions.
Keeping the lesion in the same field of view during elasticity image acquisition can
eliminate it.

Figure 25 (A) The image on the left in the dual-screen display is the B-mode
image, whereas the image on the right is the elastogram. The elastogram shows
Physics
the characteristic artifact, a black area (red arrow) with a central bright spot (green A white ring or group of waves around a lesion on the
arrow) and posterior bright spot (blue arrow). (B) A different artifact is seen in cysts
on the Hitachi system. This artifact has three-colored layers with a blue-green-red elastogram indicates the lesion is moving in and out of the
(BGR) pattern. imaging plane while the elastogram is being obtained. This
is called a sliding artifact.23 Having the lesion remain within
the imaging plane during the acquisition can eliminate the
This artifact can be used to decrease the number of breast artifact. Repositioning the patient, using less compression,
biopsies performed.20 In one series, 10% of complicated or having the patient hold their breath may help keep the
cysts appeared as solid masses on B-mode that could be lesion in the scanning plane. This artifact suggests the lesion
identified as complicated cysts with this technique. If core is freely moveable within the adjacent tissues and is most
biopsies are performed, notifying the pathologist the lesion likely benign.
is a complicated cyst as opposed to a solid mass will lead
to better pathology/imaging correlation. If the pathologist is
Artifact due to
told the lesion is solid, he may not mention that a cyst wall
Improper scanning technique.
is present and suggest the suspected solid lesion is not in
the specimen, leading to nonspecific diagnosis. This useful
artifact is seen with Siemens and Philips equipment and may Where it commonly occurs
not be seen in other manufacturers’ equipment.20 Lesions that can slip laterally under the transducer, eg,
The Hitachi system has a different artifact that occurs in fibroadenoma, lipoma.
cysts (Figure 25B). There is a three-color layering pattern of
blue, green, and red (chorine) identified in cystic lesions.21–23 Worm pattern (strain)
A detailed study evaluating the sensitivity and specificity of Appearance
this artifact has not been performed. A pattern of changing stiffness in the image (Figure 27).

Artifact due to
Algorithm.

Where it commonly occurs

Both simple and complex benign cysts.

Note
The artifact is vendor-specific.

Sliding artifact (strain)

Figure 27 Elastogram of an area of fat under significant precompression has only
Appearance regions of alternating dots and tubular areas interspersed with similar black areas.
A bright ring surrounding a lesion (Figure 26). On real-time imaging, these are constantly changing form, as this represents noise.

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Hindi et al Dovepress

Physics
If there is very little variability in the elastic properties of the
tissues within the Field of View (FOV), such as when signifi-
cant precompression is applied, a pattern of varying signals
is noted, representing noise. This has been named the worm
pattern.23 There is no clinical information in these images. This
artifact can be eliminated by the use of minimal precompres-
sion and including various tissues within the field of view.23

Artifact due to
Improper scanning technique.

Where it commonly occurs

When the tissues within a field of view are of equal strain
(when moderate precompression is used).

Lack of shear-wave signal (shear wave)

Appearance
No color-coding of a lesion in shear-wave imaging
(Figure 28).

Physics
In very hard lesions, such as invasive cancers, the shear
wave may not propagate normally. No results are therefore
obtained, and the area with no results is not color-coded. In
these areas, interpretation is not possible. Shear waves will
not propagate through simple cysts, and they will not be
color-coded either (Figure 26B). The shear wave is detected
by US echo signal. Therefore when areas in B-mode image
show extremely low signals, it indicates the echo signal
is too low for successful detection. These areas are not
color-coded. This will occur in areas with marked shadow-
ing, such as ribs, tumor with significant shadowing, and areas
with calcification.23

Artifact due to
Patient factors, lesion factors.

Where it commonly occurs

In areas deeper than the shear wave is generated, in hard
or disordered structures where the shear wave contains
significant noise. Figure 28 (A and B) Problems that can be encountered with shear-wave
elastography include no signal within the lesion, which can occur because the
Precompression artifact push pulse does not start a shear wave in the mass because of the lesion depth.
(A) This invasive ductal carcinoma does not have a shear-wave signal (no color
(strain and shear wave) with the lesion) because the shear wave did not form. (B) Simple cyst. Shear waves
cannot propagate in simple cysts and therefore are not color-coded on the shear-
Appearance wave elastogram. If the cyst is complicated, the shear wave may propagate and will
be color-coded blue (low kPa value). Precompression can markedly affect the kPa
Erroneously high shear-wave velocity (shear wave) and
value of a lesion. With increased precompression, all lesions become stiffer and
increasing noise (strain) (Figure 29). therefore code with a higher kPa value.

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Dovepress Artifacts in US

Amount of precompression Understanding the cause of the artifacts can help to eliminate
A x
Significant
unwanted artifacts.

2.5
Noise
Disclosure
RGB has received equipment and research grants from
x
Mild
­Siemens Ultrasound, Philip Ultrasound and SuperSonic
Occational good
images
Imagine. He is on an advisory panel for Philips Ultrasound,
2.5

and is a lecturer for Siemens Ultrasound, Philips Ultrasound,

x
Minimal and SuperSonic Imagine.
Consistent good
2.5 images References
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