Carotid and Vertebral Ultrasonography- Dr. Daniel

8/13/2019 Carotid and Vertebral Ultrasonography- Dr. Daniel

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CAROTID AND VERTEBRAL

ULTRASONOGRAPHY

Daniel Makes

Department Of Radiology

Faculty Of Medicine University of Indonesia /

Cipto Mangunkusumo Hospital

Jakarta Indonesia


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Ultrasound is non-invasive andmore readily available thanother techniques-digitalsubtraction angiography

(DSA), computed tomographyangiography (CTA) & MRA and,uniquely, it can visualisethe arterial wall itself


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Stroke is a significantpublic health problem,with an incidence of 2,9per 1000 population inngland and Wales witha recurrence rate of

between 20 and 50within 5 years


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Thromboembolic disease isa major cause of strokesecondary toatherosclerosis, which isthe formation of fibrofattyplaques within the intima

of the arteries andarterioles


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Atherosclerotic lesions may develop

inflammatory changes, cholesterol

crystals, necrotic debris, andsubintimal haemorrhage

If the plaque ruptures, it may releasethese materials as emboli and / or

cause thrombus formation on the

ulcerated surface, thus placing thepatient at risk of cerebral

thromboembolic disease


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50-60 % of patients withtransient ischaemic attacks

(TIAs) have less than a 50 %stenosis on cerebral

arteriography

TIAs are followed by strokewithin 5 years in 33 % of

patients, the period of greatestrisk being the first two weeksafter a TIA


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The North American SymptomaticCarotid Endarterectomy Trial(NASSCET), European CarotidSurgery Trial (ECST) andAsymptomatic CarotidAtherosclerosis Study (ACAS) haveclearly demonstrated the benefit ofcarotid endarterectomy for

symptomatic patient with > 70diameter stenosis


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Prime indication ofultrasound is to identifyflow-limiting stenoses,especially high gradestenoses (> 70 ), insymptomatic patients whoare likely to benefit fromcarotid endarterectomy


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EQUIPMENT A high resolution linear transducer Duplex or triplex display mode

option (real-time grey-scale image +spectral Dopller analysis + colourflow imaging) Adjustable wall filter, ultrasound

beam angle steering, anglecorrection


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SCANNING PROTOCOL1. Patient position

Supine Neck slightly extended Head turned away from the sidebeing examined

2. Regions of interest Both CCAs from the origins to thebifurcations Both ICAs and ECAs as cephalad as

possible Both vertebral arteries(the proximal and the interforaminasegments)


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Procedure Examine the carotid arteriestransversely, followed bylongitudinal scans Record any plaque formation, itslocation, extent and morphology Quantify the degree of stenosis Examine the vertebral arteries byduplex sonography


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Handling the transducer in duplexsonography of the neck arteries


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Sectional planes used in examiningthe carotid system in the neck withduplex sonography


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Anatomy of the large arteriessupplying the brain


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Normal CCA and Bifurcation


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Normal Carotid Bifurcation


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Normal Carotid Bulb


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The normal dimensions ofthe carotid arteries are :

1. CCA : 6.3 + 0,9 mm2. ICA : 4.8 + 0,7 mm

3. ECA : 4.1 + 0,6 mm


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Normal Brachiocephalic Bifurcation


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Normal Common Carotid Artery


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Normal Internal Carotid Artery


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Normal External Carotid Artery


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Fig.11.4


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PLAQUECHARACTERISATIONPrediction of subsequent stroke byplaque morphology is controversial

Detection of ulcers in a plaquecorrelates better with the risk ofrecurrent cerebral embolismSensitivity for plaque ulceration is poorwith transcutaneous ultrasound


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CAROTID ARTERIESIntima-media thickness(IMT)

The IMT is defined as the distancebetween the leading edges ofthe lumen-intima interface and

the media-adventina interface ofthe outer wallMeasurements should be made on

a magnified view to minimise error


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The IMT ranges from0.5 mm to 1.0 mm

in healthy adults at allages, values over1.0 mm are regarded asabnormal


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Detectable atheroscleroticlesions are defined asIMT > 1.2 mm whereasmoderate to severethickening is present whenIMT is greater than 2 mm


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Soft Plaque


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Dense Plaque


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Calcified Plaque


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Ulcerated Plaque with Hemorrhage


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Calcified plaque with acousticshadowing


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Fibromuscular Hyperplasia


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a. Mild stenosisb. Moderatestenosisc. Severestenosisd. Subtotalstenosis


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Doppler spectral analysis of variousdiagnostic parameters


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Moderate stenosisa. Color doppler imageshows a color mosaicpattern representingthe stenosisb. Spectral analysisshows minimalspectral broadeningand moderatelyelevated frequencies


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Spectral Broadeninga. Minimal spectral broadening with

moderate stenosisb. Complete filling of the spectral windowwith critical stenosis


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Distal carotid siphon stenosis withabnormal proximal waveform

I t l tid t di ti


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Internal carotid artery dissection


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Tortousitya. The S-shaped

tortuous

internal carotid

arteryb. Long tortuous

internal carotid

artery

c. Tortuosity seenwith power

doppler

Brachiocephalic artery


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Brachiocephalic artery

aneurysm

a. Color Doppler image shows the aneurysmb. Angiography demonstrates the aneurysm


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Vertebral Artery


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Normal Vertebral Artery


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Atherosclerotic lesionsof the vertebral arteriescommonly occurat the origin of

the vertebral artery


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Vertebral artery calcification


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Vertebral artery stenosis


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Critical subclavian arterystenosis


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Subclavian Steala. Stenosisb. Occlusion


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CONCLUSION

You should always

increased your skillto increase your

diagnostic accuracy

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Carotid and Vertebral Ultrasonography- Dr. Daniel

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