Ultrasound reverberation artifact: help or hindrance in the examination of the uterus and endometrium?

Objective: To summarize current knowledge on the physical nature of reverberation artifact and its impact on the quality of uterine and endometrial ultrasound imaging, including possible effects on three-dimensional power Doppler indices (VI, FI, VFI).

Materials and methods. An analytical review of 85 publications in the PubMed, Scopus and eLibrary databases for 1982–2025, devoted to ultrasound imaging artifacts, reverberation physics and the use of 3D Power Doppler for endometrial assessment.

Results. Reverberation artifact results from multiple reflections of ultrasound waves between acoustically dense interfaces, producing a series of parallel echoes distal to the true structure. In B-mode, it may mimic endometrial thickening or intracavitary lesions; in color or power Doppler imaging, it can generate false flow signals. No direct quantitative studies evaluating the effect of reverberation on VI, FI, VFI were identified. However, theoretically, reverberation may lead to overestimation of VI and VFI due to the appearance of spurious color voxels.

Conclusion. Reverberation should be regarded not only as a source of diagnostic error but also as a potential diagnostic clue. Understanding its mechanisms, optimizing Doppler settings, and standardizing 3D Power Doppler protocols improve the accuracy of morphological and hemodynamic assessment of the uterus and endometrium. Further quantitative studies are warranted to determine the degree of artifact influence on vascular indices.

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