Carotid doppler II

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Published on March 20, 2014

Author: muhammadbinzulfiqar5

Source: slideshare.net

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Pathologies Carotid Doppler 4Vessels.

CAROTID DOPPLER Part II DR.MUHAMMAD BIN ZULFIQAR PGR-1 FCPS SHL

Sonographic features of severe ICA stenosis  Significant visible plaque (≥ 70% diameter reduction)  PSV > 230 cm/sec  EDV > 100 cm/sec  ICA/CCA PSV ratio ≥ 4.0  Spectral broadening  Color aliasing despite high velocity scale (100 cm/sec)  Color bruit artifact in surrounding tissue of stenosis  High-pitched sound at pulsed Doppler

Stenosis of ECA • PSV of ECA stenosis Minimal < 200 cm/sec Moderate 200 – 300 cm/sec Severe > 300 cm/sec • ECA/CCA systolic ratio* < 2 ≤ 50% Ø stenosis ≥ 2 ≥ 70% Ø stenosis Isolated ECA stenosis not clinically significant

PART II 1. Vertebral Artery 2. Pathologies other than Arteriosclerotic Disease 3. Effect of extra-carotid diseases

Vertebral artery course V1 V0 V2 V3 V4 BA VAs asymmetric in 75 % – Left dominant in 80 % Posteriorly directed loop when exists C1 transverse process 2 VAs unite to form basilar artery: collateralization

Ultrasound of normal vertebral vessels Cephalad flow throughout cardiac cycle Low resistance flow pattern VA origin regularly seen by experienced sonographers Size: variable & asymmetric – Mean diameter 4 mm PSV: 20 – 40 cm/sec – <10 cm/sec potentially abnormal Vertebral artery Vertebral vein May occasionally be seen adjacent to VA Flow caudad & nonpulsatile

Schematic Doppler waveforms of VA

High-resistance flow in vertebral artery High-resistance flow No diastolic component Distal VA stenosis or occlusion Hypoplastic vertebral artery Differential diagnosis: Dizziness Unsteady walking Correlation with symptoms

Route of flow in left vertebral steal

Subclavian steal phenomenon refers to steno-occlusive disease of the proximal subclavian artery with retrograde flow in ipsilateral vertebral artery

Types of subclavian steal Transient reversal of vertebral flow during systole Converted to partial or complete by provocative maneuver Pre-steal or bunny waveform Striking deceleration of velocity in mid or late systole High-grade stenosis of subclavian rather than occlusion Incomplete steal Complete reversal of flow within vertebral artery Complete steal

Vertebral to subclavian steal Presteal Incomplete steal Complete steal Compared to bunny in profile

Provocative maneuver in steal syndrome Conversion of pre-steal waveform to more pronounced steal following deflation of pressure cuff Inflation of pressure cuff on arm for 3 min & rapid deflation By exercising the diseased limb also cause provocation Pre-steal More pronounced steal

Causes of carotid artery diseases Arteriosclerotic disease Non-arteriosclerotic diseases Fibromuscular dysplasia Dissection Vasospasm Aneurysm & pseudoaneurysm Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia Most common cause

Fibromuscular dysplasia Middle age women – Renal arteries – String of beads pattern Alternating zones of vasoconstriction & vasodilatation for 3 – 5 cm ICA frequently – VA less frequently Usually bilateral ICA

Causes of carotid artery diseases Arteriosclerotic disease Non-arteriosclerotic diseases Fibromuscular dysplasia Dissection Vasospasm Aneurysm & pseudoaneurysm Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia Most common cause

Carotid & vertebral dissection • Spontaneous dissection Bleeding from vasa vasorum Most common ICA & VA (atlas loop) Intramural hematoma Pain – Stenosis – Horner • Vascular injury Iatrogenic: puncture – surgery CCA Intramural hematoma ± intimal tear • Stanford A dissection Intimal rupture in ascending aorta CCA

Dissection of aorta & cervical arteries Patho-anatomy Intimal rupture with false lumen Open or secondarily thrombosed Aorta External intramural hematoma Lumen constriction Rare intimal rupture Cervical

Spontaneous dissection of ICA Asymmetric wall hematoma – Lumen stenosis – Expansion to outside Diagnostic criteria (one sufficient) Intramural hematoma Intimal rupture/double lumen Distal stenosis or occlusion Symptoms: acute pain, Horner, Course: recanalization in few weeks a Longitudinal color Doppler ultrasound (US) image of an acute dissection of the internal carotid artery (ICA) with the dissection of the lumen (arrowhead) demonstrating color flow. ICA large arrow, external carotid artery (ECA) long arrow. b An abnormal high-resistance spectral Doppler US waveform is demonstrated in the dissection lumen (arrowhead). ICA large arrow, ECA long arrow. c. On day 14, there is intramural thrombus formation (arrowhead) with no evidence of color Doppler US flow within the dissection false lumen. CCA star, ICA large arrow, ECA long arrow

Spontaneous dissection of VA Wall hematoma in V1 Diagnostic criteria (one sufficient): Intramural hematoma (asymmetric, not concentric) Intimal rupture/double lumen (rare) Double lumen in V2

Dissection of common carotid artery Transverse view Longitudinal view Detection of two lumina & dissection membrane

Dissection of CCA / Stenosis Residuum after end of aortic dissection Doppler of true lumen Enlargement of false lumen before cranial end Doppler of false lumen Stenosis of true lumen

Causes of carotid artery diseases Arteriosclerotic disease Non-arteriosclerotic diseases Fibromuscular dysplasia Dissection Vasospasm Aneurysm & pseudoaneurysm Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia Most common cause

Vasospasm • Causes Migraine, eclampsia, vasculitis, drug abuse, idiopathic • Incidence Rarely identified (short duration) Occur frequently & remain undetected • Symptoms Cerebral or ocular ischemia • US Direct &/or indirect signs of severe stenosis Far above bifurcation – Sometimes bilateral Complete regression in hours to days – Relapse • DD Dissection: wall hematoma – regression in weeks • Treatment Calcium antagonists

Vasospasm Severe narrowing of ICA No stenosis detected 4 days later

Causes of carotid artery diseases Arteriosclerotic disease Non-arteriosclerotic diseases Fibromuscular dysplasia Dissection Vasospasm Aneurysm & pseudoaneurysm Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia Most common cause

Extra-cranial ICA aneurysms Color Doppler US Power Doppler US Incomplete delineation of aneurysm – Thrombi could not be excluded Difficult definition for extracranial carotid artery aneurysms due to normal dilatation of bulb

ICA aneurysm / Parietal thrombosis Aneurysm of proximal ICA Parietal thrombus & homogeneous thickening of vessel wall Longitudinal section Transversal section

CCA aneurysm / Rupture

CCA pseudoaneurysm / Rare One month after bilateral neck dissection CCA Pseudoaneurysm Large connecting neck Color Doppler US CE multidetector CT CCA Pseudoaneurysm Large connecting neck

Causes of carotid artery diseases Arteriosclerotic disease Non-arteriosclerotic diseases Fibro muscular dysplasia Dissection Vasospasm Aneurysm & pseudoaneurysm Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia Most common cause

Arterio-venous fistula Attempt to perform US-guided jugular catheter insertion Turbulent flow in fistula track High-velocity turbulent flow in track Suspicion of communication between CCA & IJV CCA IJV

Causes of carotid artery diseases Arteriosclerotic disease Non-arteriosclerotic diseases Fibro muscular dysplasia Dissection Vasospasm Aneurysm & pseudoaneurysm Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia Most common cause

Doppler ultrasound in arteritis “macaroni sign” & “halo sign” • 2 types Takayasu Young female – SCA & CCA Horton Old female – SCA, AA & Temporal A Cannot be differentiated using US • US signs Macaroni Concentric hypoechoic wall thickening Halo Dark halo around colorful lumen All grades of stenosis – Thrombotic vessel • DD Dissection Eccentric hypoechoic wall thickening Pronounced outward expansion

Takayasu’s arteritis Young female – SCA [‘pulseless’ disease] – CCA CCA Long hypoechoic wall thickening Visualized in color Doppler as dark halo around vascular lumen

Horton's arteritis / Giant cell arteritis Concentric hypoechoic wall thickening Superficial temporal artery VA – Longitudinal view VA – Transverse view

Causes of carotid artery diseases Arteriosclerotic disease Non-arteriosclerotic diseases Fibromuscular dysplasia Dissection Vasospasm Aneurysm & pseudoaneurysm Arteriovenous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia Most common cause

Carotid body tumor / Rare Histology Paraganglioma of low malignant potential Presentation Palpable neck mass – Headache – Neck pain US Highly vascular mass in carotid bifurcation Arteriography Performed preoperatively – Embolization Treatment Resection to prevent local adverse events: Laryngeal nerve palsy – carcinoma invasion Result Local recurrence 6% – Distant metastasis 2%

Carotid body tumor Highly vascular mass in carotid bifurcation

Causes of carotid artery diseases Arteriosclerotic disease Non-arteriosclerotic diseases Fibromuscular dysplasia Dissection Vasospasm Aneurysm & pseudoaneurysm Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia Most common cause

Diagnosis of idiopathic carotidynia International Headache Society (IHS)1 • At least one of following over CA: Tenderness Swelling Increased pulsations • Pain over affected side of neck that may project to head • Appropriate investigations without structural abnormality Recent publications demonstrate radiological findings2 • Self-limiting syndrome of less than 2 weeks duration

Idiopathic carotidynia US findings comparable to dissection Enhanced tissue around carotid artery CE T1-weighted MRIUS of distal CCA Hypo-echoic soft tissue around carotid artery Three months later Resolution of abnormal soft tissue

Spontaneous dissection & carotidynia Spontaneous dissection Carotidynia Location Beyond bifurcation At or near bifurcation Thickening layers One wall layer 2 wall layers Stenosis May be detectable Not detectable Pain Head Neck In unclear cases, MRI enables differentiation

Doppler US of carotid arteries  Anatomy of carotid arteries  Normal Doppler US of carotid arteries  Causes of carotid artery disease  Effect of extra-carotid diseases

Effect of extra-carotid diseases • Idiopathic dilated cardiomyopathy • Aortic regurgitation • Aortic stenosis • Stenosis of right innominate artery or origin of LCCA • High & low PSV in CCA • Stenosis of intra-cranial ICA

Idiopathic dilated cardiomyopathy Pulsus alternans PSV oscillating between two levels on sequential beats Cardiac rhythm remains regular throughout

Aortic regurgitation Bisferiens waveform [“beat twice” in Latin] Two systolic peaks separated by midsystolic retraction Dicrotic notch Found also with hypertrophic obstructive cardiomyopathy

Severe aortic regurgitation Normal or elevated PSV followed by precipitous decline Revered flow during diastole Water-hammer spectral appearance CCA

Aortic stenosis RCCA – Tardus Parvus LCCA – Tardus Parvus RVA – Tardus Parvus

Right innominate artery stenosis RCCA – Tardus-Parvus LCCA – Normal waveform RVA – Reversed flow

Right innominate artery stenosis RICA : to-and-fro flow RCCA : to-and-fro flow RVA : reversed flow RSCA : damped flow Right carotid steal

High cardiac output: Hypertensive patients Young athletes High flow > 125 cm/sec in both CCAs Poor cardiac output: Cardiomyopathies Valvular heart disease Extensive myocardial infarction Low flow < 45 cm/sec in both CCAs Arrhythmias can be real problem Normal PSV in CCA (45 – 125 cm/sec)

ICA High-grade stenosis distally (intracranial ICA) Major occlusive lesions of cerebral arteries (MCA, ACA) Massive spasm of cerebral arteries from intracranial hemorrhage Stenosis of intra-cranial ICA High resistance waveform

Advantages of power mode Doppler • Angle independent • No aliasing • Increases accuracy of grading stenosis • Distinguish pre-occlusive from occlusive lesions “detect low-velocity blood flow” • Superior depiction of plaque surface morphology

Disadvantages of power mode Doppler • Does not provide direction of flow New machines provide direction of flow in power mode • Does not provide velocity flow information • Very motion sensitive (poor temporal resolution)

Causes of image/Doppler mismatch • Cardiac arrhythmia • Severe aortic stenosis • Hypotension or hypertension • Tortuous vessels • Hypoechoic, anechoic or calcified plaques • Long segment high grade stenosis • Pre-occlusive lesion • Tandem lesion • Contra-lateral carotid stenosis • Carotid dissection

Limitations of carotid US examination • Short muscular neck • High carotid bifurcation • Tortuous vessels • Calcified shadowing plaques • Surgical sutures, postoperative hematoma, central line • Inability to lie flat in respiratory or cardiac disease • Inability to rotate head in patients with arthritis • Uncooperative patient

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