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Carotid doppler ii

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CAROTID DOPPLER Part II DR.MUHAMMAD BIN ZULFIQAR PGR 1 FCPS SHL
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Page 1: Carotid doppler ii

CAROTID DOPPLERPart II

DR.MUHAMMAD BIN ZULFIQARPGR 1 FCPS SHL

Page 2: Carotid doppler ii

PART II

1. Vertebral Artery2. Pathologies other than Arteriosclerotic

Disease3. Effect of extra-carotid diseases

Page 3: Carotid doppler ii

Internalization of ECA

Patient with complete occlusion of left ICA

Page 4: Carotid doppler ii

Stenosis of ECA

• PSV of ECA stenosis Minimal < 200 cm/sec “Guesstimate” Moderate 200 – 300 cm/sec

Severe > 300 cm/sec

• ECA/CCA systolic ratio* < 2 ≤ 50% Ø stenosis ≥ 2 ≥ 70% Ø stenosis

* Päivänsalo MJ et al. Acta Radiologica 1996 ; 37 : 41 – 43.

Isolated ECA stenosis not clinically significant

Page 5: Carotid doppler ii

Occlusion of CCA

Robbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.

Reversed flow from ECA

to supply ICA & brain

“ECA-to-ICA collateralization”

Page 6: Carotid doppler ii

Occlusion of CCA

Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.

Absence of flow in distal CCAReversed flow in ECANormal flow in ICA

Internalization of ECADelayed systolic acceleration (tardus)

Positive temporal tap maneuver

Page 7: Carotid doppler ii

Ectatic CCA

Ectatic CCA as it arises from innominate artery

Responsible for pulsatile right supra-clavicular mass

Page 8: Carotid doppler ii

Schematic Doppler waveforms of VA

Page 9: Carotid doppler ii

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

Page 10: Carotid doppler ii

Vertebral artery occlusionV2

Black & white US Color Doppler

Page 11: Carotid doppler ii

Route of flow in left vertebral steal

Page 12: Carotid doppler ii

Types of subclavian steal

Transient reversal of vertebral flow during systoleConverted to partial or complete by provocative

maneuver

Pre-steal or bunny waveform

Striking deceleration of velocity in mid or late systoleHigh-grade stenosis of subclavian rather than occlusion

Incomplete steal

Complete reversal of flow within vertebral artery

Complete steal

Page 13: Carotid doppler ii

Vertebral-to-subclavian steal

Presteal

Incomplete steal

Complete steal

Compared to bunny in profile

Rohren EM et al. Am J Roentgenol 2003 ; 181 : 1695 – 1704.

Page 14: Carotid doppler ii

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*

Pre-steal More pronounced steal

Page 15: Carotid doppler ii

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

Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.

Page 16: Carotid doppler ii

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

Page 17: Carotid doppler ii

Disadvantages of power mode Doppler

• Does not provide direction of flowNew machines provide direction of flow in power mode

• Does not provide velocity flow information

• Very motion sensitive (poor temporal resolution)

Page 18: Carotid doppler ii

Causes of carotid artery diseases

Arteriosclerotic disease

Non-arteriosclerotic diseasesFibromuscular dysplasia DissectionVasospasm Aneurysm & pseudoaneurysm

Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia

Most common cause

Page 19: Carotid doppler ii

Fibromuscular dysplasiaMiddle age women – Renal arteries – String of beads pattern

Alternating zones of vasoconstriction & vasodilation for 3 – 5 cm

ICA frequently – VA less frequently

Usually bilateral

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

ICA

Page 20: Carotid doppler ii

Causes of carotid artery diseases

Arteriosclerotic disease

Non-arteriosclerotic diseasesFibromuscular dysplasia DissectionVasospasm Aneurysm & pseudoaneurysm

Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia

Most common cause

Page 21: Carotid doppler ii

Carotid & vertebral dissection

• Spontaneous dissection Bleeding from vasa vasorum Most common ICA & VA (atlas loop)

Intramural hematomaPain – Stenosis – Horner

• Vascular injury Iatrogenic: puncture – surgeryCCAIntramural hematoma ± intimal tear

• Stanford A dissection Intimal rupture in ascending aortaCCA

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Page 22: Carotid doppler ii

Dissection of aorta & cervical arteries

Patho-anatomy

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Intimal rupture with false lumenOpen or secondarily thrombosed

Aorta

External intramural hematomaLumen constrictionRare intimal rupture

Cervical

Page 23: Carotid doppler ii

Spontaneous dissection of ICAAsymmetric wall hematoma – Lumen stenosis – Expansion to outside

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Diagnostic criteria (one sufficient) Intramural hematoma Intimal rupture/double lumen Distal stenosis or occlusion Symptoms: acute pain, Horner, Course: recanalization in few weeks

Page 24: Carotid doppler ii

Spontaneous dissection of VA

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Wall hematoma in V1

Diagnostic criteria (one sufficient):

Intramural hematoma (asymmetric, not concentric)

Intimal rupture/double lumen (rare)

Double lumen in V2

Page 25: Carotid doppler ii

Thoracic aortic dissectionStanford classification

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Type B

Dissection of descending aorta Dissection of ascending aorta

Possible continuation to supraaortic vessels

Type A

Page 26: Carotid doppler ii

Dissection of common carotid arteryStanford A

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Transverse view Longitudinal view

Detection of two lumina & dissection membrane

Page 27: Carotid doppler ii

Dissection of CCA / Stenosis Residuum after end of aortic dissection

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Doppler of true lumen

Enlargement of false lumen

before cranial end

Doppler of false lumen

Stenosis of true lumen

Page 28: Carotid doppler ii

Causes of carotid artery diseases

Arteriosclerotic disease

Non-arteriosclerotic diseasesFibromuscular dysplasia DissectionVasospasm Aneurysm & pseudoaneurysm

Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia

Most common cause

Page 29: Carotid doppler ii

Vasospasm

• Causes Migraine, eclampsia, vasculitis, drug abuse, idiopat

• 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

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Page 30: Carotid doppler ii

Vasospasm Severe narrowing of ICA No stenosis detected

4 days later

Page 31: Carotid doppler ii

Causes of carotid artery diseases

Arteriosclerotic disease

Non-arteriosclerotic diseasesFibromuscular dysplasia DissectionVasospasm Aneurysm & pseudoaneurysm

Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia

Most common cause

Page 32: Carotid doppler ii

Extra-cranial ICA aneurysmsColor Doppler US Power Doppler US

Incomplete delineation of aneurysm – Thrombi could not be excluded

Difficult definition for extracranial carotid artery aneurysmsdue to normal dilatation of bulb

Page 33: Carotid doppler ii

ICA aneurysm / Parietal thrombosis

Aneurysm of proximal ICA

Parietal thrombus & homogeneous thickening of vessel wall

Longitudinal section Transversal section

Page 34: Carotid doppler ii

CCA aneurysm / Rupture

Clevert DA et al. Clin Hemorheology Microcirculation 2008 ; 39 : 133 – 146.

Page 35: Carotid doppler ii

CCA pseudoaneurysm / Rare

One month after bilateral neck dissection

Flor N et al. J Laryngol Otol 2007 ; 121 : 497 – 500.

CCA PseudoaneurysmLarge connecting neck

Color Doppler US CE multidetector CT

CCA PseudoaneurysmLarge connecting neck

Page 36: Carotid doppler ii

Causes of carotid artery diseases

Arteriosclerotic disease

Non-arteriosclerotic diseasesFibro muscular dysplasia DissectionVasospasm Aneurysm & pseudoaneurysm

Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia

Most common cause

Page 37: Carotid doppler ii

Arterio-venous fistulaAttempt to perform US-guided jugular catheter insertion

Turbulent flow in fistula track High-velocity turbulent flow in track

Suspicion of communication between CCA & IJV

CCAIJV

Page 38: Carotid doppler ii

Causes of carotid artery diseases

Arteriosclerotic disease

Non-arteriosclerotic diseasesFibro muscular dysplasia DissectionVasospasm Aneurysm & pseudoaneurysm

Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia

Most common cause

Page 39: Carotid doppler ii

Doppler ultrasound in arteritis“macaroni sign” & “halo sign”

• 2 types Takayasu Young female – SCA & CCAHorton Old female – SCA, AA & Temporal ACannot be differentiated using US

• US signs Macaroni Concentric hypoechoic wall thickeningHalo Dark halo around colorful lumenAll grades of stenosis – Thrombotic vessel

• Dd Dissection Eccentric hypoechoic wall thickening Pronounced outward expansion

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Page 40: Carotid doppler ii

Takayasu’s arteritis Young female – SCA [‘pulseless’ disease] – CCA

CCA

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Long hypoechoic wall thickening

Visualized in color Doppler as dark halo around vascular lumen

Page 41: Carotid doppler ii

Horton's arteritis / Giant cell arteritis

Concentric hypoechoic wall thickeningSuperficial temporal artery

VA – Longitudinal view VA – Transverse view

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Page 42: Carotid doppler ii

1 sAUROC: Summary Area Under Receiver Operating Characteristic2 DOR: Diagnostic Odds Ratio

Ball EL et al. Br J Surg 2010 ; 97 : 1765 – 1771.

MA of US in diagnosis of temporal arteritis

Halo sign versus temporal artery biopsy

9 studies – 357 patients

Sensitivity 75% (67 – 82)

Specificity 83% (78 – 88)

sAUROC1 0.868

DOR2 17.96 (6.72 – 47.99)

Heterogeneity I2 = 27%, P < 0.204

US relatively accurate for diagnosis of temporal arteritisUS as first-line investigation, biopsy if negative scan

Page 43: Carotid doppler ii

Causes of carotid artery diseases

Arteriosclerotic disease

Non-arteriosclerotic diseasesFibromuscular dysplasia DissectionVasospasm Aneurysm & pseudoaneurysm

Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia

Most common cause

Page 44: Carotid doppler ii

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%

Page 45: Carotid doppler ii

Carotid body tumor Highly vascular mass in carotid bifurcation

Zwiebel WL. Introduction to vascular ultrasonography.W.B. Saunders, Philadelphia, USA, 4th edition, 2000.

Page 46: Carotid doppler ii

Causes of carotid artery diseases

Arteriosclerotic disease

Non-arteriosclerotic diseasesFibromuscular dysplasia DissectionVasospasm Aneurysm & pseudoaneurysm

Arterio-venous fistula Arteritis: Takayasu – Horton Carotid body tumor Idiopathic carotidynia

Most common cause

Page 47: Carotid doppler ii

Diagnosis of idiopathic carotidyniaInternational Headache Society (IHS)1

• At least one of following over CA: TendernessSwellingIncreased pulsations

• Pain over affected side of neck that may project to head

• Appropriate investigations without structural abnormalityRecent publications demonstrate radiological findings2

• Self-limiting syndrome of less than 2 weeks duration

1 International Headache Society. Cephalalgia 1988 ; 8 (Suppl 7) : 1 – 96.2 Kosaka N et al. Eur Radiol 2007 ; 17 : 2430 – 2433.

Page 48: Carotid doppler ii

Idiopathic carotidynia

US findings comparable to dissection

Kosaka N et al. Eur Radiol 2007 ; 17 : 2430 – 2433.

Enhanced tissuearound carotid artery

CE T1-weighted MRIUS of distal CCA

Hypo-echoic soft tissuearound carotid artery

Three months later

Resolution of abnormalsoft tissue

Page 49: Carotid doppler ii

Spontaneous dissection & carotidynia

Spontaneous dissection Carotidynia

Location Beyoud bifurcation At or near bifurcation

Thickening layersOne wall layer 2 wall layers

Stenosis May be detectable Not detectable

Pain Head Neck

MRI Native enhancement Enhancement after CAs

In unclear cases, MRI enables differentiation

Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

Page 50: Carotid doppler ii

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

Page 51: Carotid doppler ii

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

Page 52: Carotid doppler ii

Idiopathic dilated cardiomyopathy

Pulsus alternans

Rohren EM et al. Am J Roentgenol 2003 ; 181 : 1695 – 1704.

PSV oscillating between two levels on sequential beats

Cardiac rhythm remains regular throughout

Page 53: Carotid doppler ii

Aortic regurgitation

Bisferious waveform [“beat twice” in Latin]

Kallman CE et al. Am J Roentgenol 1991 ; 157 : 403 – 407.Rohren EM et al. AJR 2003 ; 181 : 169 5– 1704.

Two systolic peaks separated by midsystolic retractionDicrotic notch

Found also with hypertrophic obstructive cardiomyopathy

Page 54: Carotid doppler ii

Severe aortic regurgitation

Rohren EM et al. Am J Roentgenol 2003 ; 181 : 1695 – 1704.

Normal or elevated PSV followed by precipitous declineRevered flow during diastole

Water-hammer spectral appearance

CCA

Page 55: Carotid doppler ii

Aortic stenosis

Scoutta LM et al. Ultrasound Clin 2006 ; 1 : 133 – 159.

RCCA – Tardus-Parvus LCCA – Tardus-Parvus

RVA – Tardus-Parvus

Page 56: Carotid doppler ii

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

RVA – Reversed flow

Page 57: Carotid doppler ii

Right innominate artery stenosis

RICA : to-and-fro flow

RCCA : to-and-fro flow

RVA : reversed flow

RSCA : damped flow

Right carotid steal

Page 58: Carotid doppler ii

High cardiac output: Hypertensive patientsYoung athletes

High flow > 125 cm/sec in both CCAs

Poor cardiac output: CardiomyopathiesValvular heart diseaseExtensive myocardial

infarction

Low flow < 45 cm/sec in both CCAs

Arrhythmias can be real problem

Normal PSV in CCA (45 – 125 cm/sec)

Page 59: Carotid doppler ii

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 ICAHigh resistance waveform

Page 60: Carotid doppler ii

References

Elsevier – 2005 Springer-Verlag – 2011

C. Arning et al. Ultraschall Med 2008 ; 31 : 576 – 599.

Page 61: Carotid doppler ii

Thank You


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