Ultrasound Artifacts Versus Pathological and Normal Anatomical Variants



Ultrasound Artifacts Versus Pathological and Normal Anatomical Variants


Sharon L. McCartney

Jeffrey T. Lyvers





1. The artifact in Figure 16.1 (arrow) violates which assumption of ultrasound wave propagation?







A. Ultrasound propagates in a straight line in the direction of the central beam


B. A structure will reflect the ultrasound beam only once


C. Only structures located within the intended path of the ultrasound beam will generate reflections back to the transducer


D. The position of the structure along the scan line is proportional to the travel time of the transmitted wave

View Answer

1. Correct Answer: B. A structure will reflect the ultrasound beam only once

Rationale: Reverberation artifacts are created when the ultrasound beam bounces multiple times between two highly reflective surfaces during the listening phase, before returning to the transducer. This violates the assumption that the ultrasound has returned to the transducer after only a single reflection from the structure. Because the ultrasound beam bounces between two strong reflectors during the listening phase, the reverberation artifact lies distal to the imaged structure and often violates anatomic boundaries. When the distance between the two reflectors is small, the artifact will appear as closely approximated lines (or stepladder), creating a “ring-down” or “comet-tail” artifact.

Selected References

1. Bertrand PB, Levine RA, Isselbacher EM, Vandervoort PM. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis. J Am Soc Echocardiogr. 2016;29(5):381-391.

2. Le HT, Hangiandreou N, Timmerman R, et al. Imaging artifacts in echocardiography. Anesth Analg. 2016;122(3):633-646.




2. A 65-year-old patient with chronic obstructive pulmonary disease presents with three-vessel coronary artery disease for coronary artery bypass grafting. A transesophageal echocardiogram (ECG) is performed prior to the procedure. Identify the structure in Figure 16.2 (arrow).







A. Pulmonary embolus


B. Pulmonary artery sarcoma


C. Near-field artifact


D. Beam width artifact

View Answer

2. Correct Answer: C. Near-field artifact

Rationale: Structures in the near field are sometimes obscured by high-amplitude oscillations by the transducer itself, causing near-field artifacts. These are often seen in structures that are close to the transducer, such as the pulmonary arteries or descending aorta. True pulmonary embolus moves with cardiac motion and will show a lack of color with color flow Doppler. With the addition of color flow Doppler on a near-field artifact, the color will encompass the entire pulmonary artery, without filling defects. In the patient scenario, this patient is coming to the operating room for coronary artery bypass grafting, without evidence of right heart strain or hypoxemia. This helps us to identify from the stem that this is an artifact. Contrast the image in the stem from the image in Figure 16.16 which is a pulmonary embolus. This image shows a discrete mass and filling defect in the right pulmonary artery.






Selected Reference

1. Bertrand PB, Levine RA, Isselbacher EM, Vandervoort PM. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis. J Am Soc Echocardiogr. 2016;29(5):381-391.



3. The imaging artifact in Figure 16.3 violates which assumption of ultrasound principles?







A. Echoes return to the transducer after a single reflection


B. Echoes originate from the main beam


C. The depth of an object is directly related to the travel time for an ultrasound pulse to return to the transducer


D. Pulses are propagated uniformly by all tissues

View Answer

3. Correct Answer: D. Pulses are propagated uniformly by all tissues

Rationale: The prosthetic aortic valve in Figure 16.3 acts as a strong reflector preventing ultrasound wave propagation beyond the valve. This creates an artifact called acoustic shadowing. Acoustic shadowing violates the assumption that pulses are propagated uniformly by all tissues. In this case, the prosthetic valve attenuates the pulse distal to the valve.

Selected References

1. Bertrand PB, Levine RA, Isselbacher EM, Vandervoort PM. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis. J Am Soc Echocardiogr. 2016;29(5):381-391.

2. Le HT, Hangiandreou N, Timmerman R, et al. Imaging artifacts in echocardiography. Anesth Analg. 2016;122(3):633-646.




4. A 56-year-old male is undergoing a mitral valve replacement via thoracotomy. What is shown in Figure 16.4 (arrow)?







A. Crista terminalis


B. Side-lobe artifact


C. Chiari network


D. Eustachian valve

View Answer

4. Correct Answer: D. Eustachian valve

Rationale: The Eustachian valve is an embryologic remnant that can be seen as a prominent crescent-shaped tissue at the posterior aspect of the inferior vena cava. In fetal life, it directed blood flow across the fossa ovalis. In this view (Figure 16.4), the Eustachian valve separates the inferior vena cava (above) from the coronary sinus (below). A Chiari network is a remnant of the right valve of the sinus venosus and appears as a filamentous structure in the right atrium. The crista terminalis is a ridge of myocardium at the junction of the right atrium and superior vena cava.

Selected Reference

1. Silvestry FE, Cohen MS, Armsby LB, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr. 2015;28(8):910-958.



5. In Figure 16.5, which Doppler artifact is shown?







A. Aliasing


B. Spectral Doppler mirroring


C. Pseudoflow


D. Twinkling

View Answer

5. Correct Answer: B. Spectral Doppler mirroring

Rationale: The duplication of the Doppler spectrum above and below the baseline represents spectral Doppler mirroring. This mirroring is caused by cross-talk, which is erroneous signal transfer when the echo exceeds the operating range of the circuit and results in the appearance of velocities on both sides of the baseline; or by directional ambiguity, which is when the Doppler angle is near 90°. The signal is typically more intense on one side of the baseline compared to the other side. Reducing the Doppler gain in the case of cross-talk will help to resolve the spectral Doppler mirroring, while changing the image such that the Doppler beam intersects close to 0° is helpful in directional ambiguity.

Selected Reference

1. Le HT, Hangiandreou N, Timmerman R, et al. Imaging artifacts in echocardiography. Anesth Analg. 2016;122(3):633-646.




6. The artifact in Figure 16.6 violates which assumption of ultrasound principles?







A. Echoes return to the transducer after a single reflection


B. Pulses travel in a straight line


C. Echoes originate from the main beam


D. Pulses are attenuated uniformly by all tissues

View Answer

6. Correct Answer: A. Echoes return to the transducer after a single reflection

Rationale: In Figure 16.6, the ultrasound reaches the descending aorta before reaching a strong reflector. The strong reflector then creates a mirror image of the descending aorta inferior to the actual aorta. Mirror images occur because the ultrasound pulse reaches a smooth strong reflector (mirror), which directs the beam to the second reflector (in this case, the descending aorta). The beam then bounces from the target to the mirror-like surface on its return to the probe.

Selected References

1. Bertrand PB, Levine RA, Isselbacher EM, Vandervoort PM. Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis. J Am Soc Echocardiogr. 2016:29(5):381-391.

2. Le HT, Hangiandreou N, Timmerman R, et al. Imaging artifacts in echocardiography. Anesth Analg. 2016;122(3):633-646.



7. A 65-year-old female with a past medical history of osteoporosis and severe mitral regurgitation from P2 prolapse presents for elective mitral valve repair. During her comprehensive preprocedure intraoperative transesophageal echocardiogram (Figure 16.7), this is seen in her ascending aorta.






Which of the following artifacts is it most likely?


A. Ascending aortic dissection


B. Mirror image artifact


C. Side-lobe artifact


D. Beam width artifact

View Answer

7. Correct Answer: C. Side-lobe artifact

Rationale: The main ultrasound beam emits the most energy, while small portions of ultrasound energy emitted in “side-lobes” of the main ultrasound beam are often dissipated in the tissue. However, when this side-lobe energy is reflected by a strong reflector in its path, these reflections are interpreted by the scanner as originating from the central/main ultrasound beam. Numerous side-lobe artifacts can be generated as the transducer scans by sweeping in a radial direction, often merging the side-lobe images, producing a linear arc-like artifact. In the ascending aorta, side-lobe artifacts from highly reflective aortic sinotubular junctions could be mistaken for aortic dissection flaps. Because the patient in the scenario is being imaged for elective mitral repair, without a history of hypertension or connective tissue disorder, and is asymptomatic, Figure 16.7 represents a side-lobe artifact. Imaging in alternative planes and the addition of color flow Doppler can help to distinguish a side-lobe artifact from true pathology.

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Jun 9, 2022 | Posted by in CARDIOLOGY | Comments Off on Ultrasound Artifacts Versus Pathological and Normal Anatomical Variants
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