Carotid doppler II Dr. Muhammad Bin Zulfiqar
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In this part of presentation we will discuss the role of Doppler Ultrasound in the Diagnosis of other causes of stenosis and variable pattern in circulation. In my opinion this presentation will help u to identify even rare pathologies.
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Carotid doppler II Dr. Muhammad Bin Zulfiqar
- 1. CAROTID DOPPLER Part II DR.MUHAMMAD BIN ZULFIQAR PGR-1 FCPS SHL
- 2. 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
- 3. 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
- 4. PART II 1. Vertebral Artery 2. Pathologies other than Arteriosclerotic Disease 3. Effect of extra-carotid diseases
- 5. 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
- 6. 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
- 7. Schematic Doppler waveforms of VA
- 8. 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
- 9. Route of flow in left vertebral steal
- 10. Subclavian steal phenomenon refers to steno-occlusive disease of the proximal subclavian artery with retrograde flow in ipsilateral vertebral artery
- 11. 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
- 12. Vertebral to subclavian steal Presteal Incomplete steal Complete steal Compared to bunny in profile
- 13. 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
- 14. 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
- 15. 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
- 16. 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
- 17. 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
- 18. 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
- 19. 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
- 20. 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
- 21. Dissection of common carotid artery Transverse view Longitudinal view Detection of two lumina & dissection membrane
- 22. 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
- 23. 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
- 24. 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
- 25. Vasospasm Severe narrowing of ICA No stenosis detected 4 days later
- 26. 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
- 27. 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
- 28. ICA aneurysm / Parietal thrombosis Aneurysm of proximal ICA Parietal thrombus & homogeneous thickening of vessel wall Longitudinal section Transversal section
- 29. CCA aneurysm / Rupture
- 30. 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
- 31. 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
- 32. 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
- 33. 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
- 34. 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
- 35. Takayasu’s arteritis Young female – SCA [‘pulseless’ disease] – CCA CCA Long hypoechoic wall thickening Visualized in color Doppler as dark halo around vascular lumen
- 36. Horton's arteritis / Giant cell arteritis Concentric hypoechoic wall thickening Superficial temporal artery VA – Longitudinal view VA – Transverse view
- 37. 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
- 38. 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%
- 39. Carotid body tumor Highly vascular mass in carotid bifurcation
- 40. 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
- 41. 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
- 42. 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
- 43. 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
- 44. 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
- 45. 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
- 46. Idiopathic dilated cardiomyopathy Pulsus alternans PSV oscillating between two levels on sequential beats Cardiac rhythm remains regular throughout
- 47. Aortic regurgitation Bisferiens waveform [“beat twice” in Latin] Two systolic peaks separated by midsystolic retraction Dicrotic notch Found also with hypertrophic obstructive cardiomyopathy
- 48. Severe aortic regurgitation Normal or elevated PSV followed by precipitous decline Revered flow during diastole Water-hammer spectral appearance CCA
- 49. Aortic stenosis RCCA – Tardus Parvus LCCA – Tardus Parvus RVA – Tardus Parvus
- 50. Right innominate artery stenosis RCCA – Tardus-Parvus LCCA – Normal waveform RVA – Reversed flow
- 51. Right innominate artery stenosis RICA : to-and-fro flow RCCA : to-and-fro flow RVA : reversed flow RSCA : damped flow Right carotid steal
- 52. 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)
- 53. 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
- 54. 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
- 55. 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)
- 56. 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
- 57. 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
- 58. Thank You
Editor's Notes
- The ECA is an important collateral pathway in patients with ipsilateral ICA occlusion and recurrent symptoms.This may influence the surgical decisions involving revascularization of the stenotic ECA.
- Differentiation between these causes is important, as some centers are performing vertebral artery angioplasty and stent placement for significant vertebral artery stenosis.
- Wall hematoma: Wall hematoma might be incorrectly interpreted as arteritis.However, an important differentiation criterion is the eccentric location of the wall thickening in the case of dissection as known from MRI findings, while vasculitis is characterized by concentric wall thickening.Double lumen:If double are detected, a pathological Doppler curve (showing stenosis or oscillating flow) will be found in at least one of the lumina. Therefore, fenestration of the VA (an anomaly with a double lumen in one vessel segment) cannot be confused with dissection becauseof the normal flow pulse curve in both lumina.Horner:
- If 2 lumina are detected, a pathological Doppler curve (showing stenosis or oscillating flow) will be found in at least one of the lumina. Therefore, fenestration of the VA (an anomaly with a double lumen in one vessel segment) cannot be confused with dissection because of the normal flow pulse curve in both lumina.
- True aneurysm generally defined as dilation of an artery to more than 150% of its normal diameterDifficult definition for extracranial carotid artery aneurysms due to normal dilatation of bulbDe Jong et al. proposed that ECAA of the bifurcation are better defined as a bulb dilatation greater than 200% of the diameter of the ICA or 150% of the diameter of the common carotid artery, and distal aneurysms of the extracranial internal carotid arteries (EICAA) as a dilatation greater than 120% of the diameter of the normal ipsilateral ICA.
- Temporal (giant cell) arteritis affects the superficial temporal arteries in older women.The specificity of the method under qualified application is 97%. Therefore, given a clear vasculitis finding in the ultrasound image and an experienced examiner, a vascular biopsy can be dispensed with.In the case of unclear ultrasound findings or ultrasound findings without pathological findings and a clinical suspicion of arteritis, biopsy is still necessary.
- “carotidynia” was initially described by Fay in 1927.Clinical criteria for dg of idiopathic carotidynia were established in 1988 by International Headache Society Classification Committee.The existence of this entity remained controversial and led the International Headache Society to remove carotidynia from their main classification of Headache Disorders in 2004.Severe pain on one side in the upper cervical region that responds well to cortisone or NSAIDs.
- Pulsus alternans: نبض متناوبPatient with pulsus alternans caused by idiopathic dilated cardiomyopathy.
- Pulsus bisferiens, Latin for ‘‘beat twice,’’ is the term used to describe a waveform characterized by two systolic peaks with an interposed midsystolic retraction. Visualization of this waveform suggests the presence of aortic insufficiency with or without concomitant aortic stenosis or hypertrophicobstructive cardiomyopathy.Mechanism of Pulsus bisferiens in aortic insufficiency is not well understood. One view is that first peak represents initial high-volume ejection of blood, which is followed by abrupt mid systolic flow deceleration caused by regurgitant valve, and second peak represents tidal wave reflected from distended aorta as it relaxes or from periphery of body.
- Water Hammer: الطرق المائي (صوت طرق الماء على جوانب الأنبوب الذي يحتويه)Hammer: مطرقةSpectral waveforms mirror physical examination finding of water-hammer pulses in patients with severe aortic regurgitation.
- Reduced right arm systolic blood pressure. A right-to-left difference of 20 mm Hg is considered significant.