Gray scale [also grayscale, grey scale = brit.] produces basically black and white images with series of shades of gray. Solid areas appear white and fluid areas appear black, varying from black at the weakest intensity to white at the strongest. Gray scale resolves artifacts as small as 1 mm. The display is made by transmitting bursts of energy and analyzing the returning signal. Gray scale pictures are limited to the gray scale tones; color pictures display more information because the color is added to the gray scale.
Most ultrasound contrast agents also improve gray scale visualization of the flowing blood to such a degree that the tissue echogenicity increases. Gray scale enhancement of flow in an organ promises to improve lesion detection, along with the ability to differentiate between normal and abnormal areas, using many of the criteria already routinely used in CT and MRI.

See also Compress, Densitometry, Triplex Exam and QB-Mode.

Harmonic imaging relies on detection of harmonics of the transmitted frequency produced by bubble oscillation. This method is widely available on ultrasound scanners and uses the same array transducers as conventional imaging. A major limitation of the use of ultrasound contrast agents is the problem that signals from the microbubbles are mixed with those from tissue. Echoes from solid tissue and red blood cells are suppressed by harmonic imaging.
In harmonic mode, the system transmits at one frequency, but is tuned to receive echoes preferentially at double that frequency, and the second harmonic echoes from the place of the bubble. Typically, the transmit frequency lies between 1.5 and 3 MHz and the receive frequency is selected by means of a bandpass filter whose center frequency lies between 3 and 6 MHz.
Color Doppler and real-time harmonic spectral Doppler modes have also been implemented and show a level of tissue motion suppression not available in conventional modes.

See also Harmonic B-Mode Imaging, and Harmonic Power Doppler.

The earliest introduction of vascular ultrasound contrast agents (USCA) was by Gramiak and Shah in 1968, when they injected agitated saline into the ascending aorta and cardiac chambers during echocardiographic to opacify the left heart chamber. Strong echoes were produced within the heart, due to the acoustic mismatch between free air microbubbles in the saline and the surrounding blood.

Solid regions have internal ultrasound echoes and are classified as echo poor, hypoechoic or hypoechogenic if there are few internal echoes. Hypoechoic structures appear dark in ultrasound imaging, more homogeneous structures are darker than heterogeneous.
Soft atherosclerotic plaque, liver adenoma or FNH appear with a nodular hypoechogenicity. As metastases close the blood vessels they infiltrate, tumor tissues become hypoechogenic after injection of contrast agent. Muscle appears relatively hypoechoic to tendon fibers, also articular hyaline cartilage appears hypoechoic.

(HyCoSy) Hysterosalpingo contrast sonography is used for evaluation of fallopian tube patency in patients with fertility problems who underwent transvaginal sonography. HyCoSy compared to more invasive techniques such as chromo-laparoscopy is rapidly becoming the screening test of choice to determine tubal patency.
Any body cavity that can be accessed can, in principle, be injected with vascular contrast. The contrast agent is instilled into the uterine cavity via a small Foley type catheter and, using transvaginal echography, the passage of the echogenic contrast along the tubes and into the adnexal peritoneum is tracked.
Hysterosalpingo contrast sonography does not offer the same anatomical and false negative results, e.g., because of tubal spasm, are possible so conventional X-ray salpingography is needed when tubal surgery is an option.

See also Endocavitary Echography, Transvaginal Sonography.