The perfect image quality is dependent on some assumptions of the propagation of ultrasound waves in tissues after generating in an imaging system. These assumptions are important for the developing of optimal ultrasound imaging systems.
A lot of steps can be taken to prevent artifacts and to improve image quality, for example beamforming is used to focus the ultrasound beam, and contrast agents decrease the reflectivity of the undesired interfaces or increase the backscattered echoes from the desired regions.

See also Coded Excitation, Validation and Refraction Artifact, Q-Value, Ultrasound Phantom, Dead Zone, Narrow Bandwidth.

(ESWL) Extracorporeal shock wave lithotripsy is a special use of kidney ultrasound, where high intensity focused ultrasound pulses are used to break up calcified stones in the kidney, bladder, or urethra. Pulses of sonic waves pulverize dense renal stones, which are then more easily passed through the ureter and out of the body in the urine. The ultrasound energy at high acoustic power levels is focused to a point exactly on the stone requiring an ultrasound scanning gel for maximum acoustic transmission.
Air bubbles in the ultrasound couplant, regardless of their size, degrade the performance of Lithotripsy and have the following effect:
Air bubbles smaller that 1/4 wavelength cause scattering of the sound waves as omni directional scatterers and less acoustic energy reaches the focal point. The result is less acoustic power at the focal point to disintegrate the kidney stone.
Air bubbles larger than 1/4 wavelength act as reflectors and deflects the acoustic energy off in a different direction. These results in less acoustic energy at the focal point.
Microbubbles dispersed throughout the ultrasound couplant layer change the average acoustic impedance of the gel layer (which reduces the total transmitted energy) and, due to refraction, change the focal point.

(MI) The mechanical index is an estimate of the maximum amplitude of the pressure pulse in tissue. It is an indicator of the likelihood of mechanical bioeffects (streaming and cavitation). The mechanical index of the ultrasound beam is the amount of negative acoustic pressure within a ultrasonic field and is used to modulate the output signature of US contrast agents and to incite different microbubble responses.
The mechanical index is defined as the peak rarefactional pressure (negative pressure) divided by the square root of the ultrasound frequency.
The FDA ultrasound regulations allow a mechanical index of up to 1.9 to be used for all applications except ophthalmic (maximum 0.23). The used range varies from 0.05 to 1.9.
At low acoustic power, the acoustic response is considered as linear. At a low MI (less than 0.2), the microbubbles undergo oscillation with compression and rarefaction that are equal in amplitude and no special contrast enhanced signal is created. Microbubbles act as strong scattering objects due to the difference in impedance between air and liquid, and the acoustic response is optimized at the resonant frequency of a microbubble.
At higher acoustic power (MI between 0.2-0.5), nonlinear oscillation occurs preferentially with the bubbles undergoing rarefaction that is greater than compression. Ultrasound waves are created at harmonics of the delivered frequency. The harmonic response frequencies are different from that of the incident wave (fundamental frequency) with subharmonics (half of the fundamental frequency), harmonics (including the second harmonic response at twice the fundamental frequency), and ultra-harmonics obtained at 1.5 or 2.5 times the fundamental frequency. These contrast enhanced ultrasound signals are microbubble-specific.
At high acoustic power (MI greater than 0.5), microbubble destruction begins with emission of high intensity transient signals very rich in nonlinear components. Intermittent imaging becomes needed to allow the capillaries to be refilled with fresh microbubbles. Microbubble destruction occurs to some degree at all mechanical indices. A mechanical index from 0.8 to 1.9 creates high microbubble destruction. The output signal is unique to the contrast agent.

The mirror artifact is similar to the reverberation artifact. Mirror image artifacts (mirroring) can occur if the acoustical impedances of the tissue is too much different and the ultrasound is reflected multiple times on tissue layers. The echo detected does not come from the shortest sound path, the sound is reflected off an angle to another interface so that like a real mirror, the artifact shows up as the virtual object.
An empyema or lung abscess can be simulated by a mirror image artifact of a hepatic cyst. This liver lesion can appear like a lesion within the lung because the wave is reflected off the diaphragm back into the liver. The angle of reflection is equal to the angle of incidence. The sound pulse hits the interfaces within the liver lesion and is reflected back to the diaphragm once again with an angle of reflection equal to the angle of incidence and then back to the transducer.
Also by a pelvic ultrasound scan the sound can be reflected off the rectal air at an angle so that the deep wall of an artifactual cyst represents the mirror image of the inferior and anterior walls of the bladder. Mirror image artifacts can cause other strange appearances such as invasion of a transitional cell carcinoma through the bladder wall.
Also called Cross Talk.

Plethysmography implies volume measurement procedures including air, impedance or strain gauge methods. Vascular plethysmography is a non-invasive measurement of the systolic blood pressure of a leg compared with that of an arm to determine circulatory capacity. The test is usually performed to rule out vascular blockages in the arms or legs, usually in combination with Doppler ultrasound.

See also Oculoplethysmography, and Pulse Volume Recording.