1. Doppler ultrasound of carotid arteries
Samir Haffar M.D.
Assistant Professor of internal medicine

2. 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

3. Extracranial cerebral arteries
All arteries that carry blood from heart up to base of skull
Right & left sides of extracranial circulation not symmetrical

4. Variants resulting from elongation of ICA

5. Variations in extracranial circulation
Few
• Left CCA & SCA share single trunk
• Left vertebral artery arising directly from aortic arch
• Right vertebral origin arising directly from aortic arch
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.

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

7. 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

8. All carotid artery examinations should be
performed with:
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
• Gray-scale US
• Color Doppler
• Power Doppler
• Spectral Doppler
Integrate gray scale, color flow, & spectral findings

9. Position for scanning the carotid arteries
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
Patient lie down in supine or semisupine position
Head hyperextended & rotated 45° away from side being examined
Higher-frequency linear transducers (≥ 7.5 MHz)

10. Doppler ultrasound of carotid arteries / Tips
• Begin each scan on same side, usually the right
• Avoid excess pressure on carotid bifurcation to avoid
– Stimulate carotid sinus Bradycardia
Syncope
Ventricular asystole
– Compress arteries to cause spurious high velocities
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.

11. Intima-Media complex
Normal value ≤ 0.8 mm
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Wall of CCA, bulb, or ICA
Best measured on far wall
Only intima & media included

12. Normal carotid bifurcation
Black & white US
ICA Larger & lateral
ECA Smaller & internal
Normal flow separation
Color Doppler ultrasound

13. Longitudinal scan to visualize carotid arteries
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
Anterior
Posterior
Lateral

14. Carotid bifurcation
Longitudinal B-mode image of carotid bifurcation
ICA & ECA seen in same plane
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.

15. Normal flow reversal zone in ICA
Velocities highest near flow divider
Flow reversal on opposite side
to flow divider
Flow reversal zone
Opposite to origin of ECA

16. Internal & external carotid artery
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
2 small branches originating from ECA
Power Doppler US

17. Standard Doppler spectral examination
Traces obtained from
• CCA Proximal – Distal
• Carotid Bulb
• ICA Proximal – Middle – Distal
• ECA Proximal
• Vertebral Artery V0 – V1 – V2
• SCA

18. Typical normal Doppler spectra
Common carotid artery
Internal carotid artery
External carotid artery
Zwiebel WL. Introduction to vascular ultrasonography.
W.B. Saunders, Philadelphia, USA, 4th edition, 2000.
PSV: 45 – 125 cm/sec
Difference between 2 sides < 15 cm/sec

19. Dicrotic notch
Normal feature
Ginat DT et al. Ultrasound Quarterly 2011 ; 27 : 81 – 85.
Closure of aortic valve with temporary cessation of forward flow
Resumption of forward flow by elastic rebound of aortic wall

20. Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
Coiling of ICA
Congenital - Bilateral - Symmetrical

21. Abnormal Doppler flow in tortuous vessel
Tortuous CCA displays color
Doppler eccentric jets of flow
High velocity due to eccentric
jet in tortuous CCA
Tortuosity can increase velocity, although there is no stenosis
Try sampling just beyond the curve

22. Temporal tap maneuver

23. Abropoulos NL et al. Vasc Endovascular Surg 2007 ; 41 : 417 – 427.
Temporal tapping of ECA
“Saw-tooth” appearance
Small regular deflections (TT)
Frequency corresponds to rate of temporal tapping
Deflections best seen during diastole

24. Temporal tap
Internal & external carotid artery findings
ICA
temporal tap
ECA
temporal tap
Normal + / − +
Significant ICA stenosis − +
Significant ECA stenosis + −
Robbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.
Not proved reliable

25. Differentiation between ICA & ECA
Features ICA ECA
 Size Usually larger Usually smaller
 Temporal tap Usually negative Usually positive
 Pulsed Doppler Low resistance High resistance
 Orientation Posterior Anterior
 Branches Rarely Yes

26. Protocol for VA examination
– Direction of flow
– Waveform configuration
– Measure PSV
Longitudinal VA between transverse processes
Cauded survey
– Follow artery cauded to its origin
Cephalad survey
– Follow artery cephalad above transverse processes

27. 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

28. Normal vertebral artery origin
V0
Zwiebel WL. Introduction to vascular ultrasonography.
W.B. Saunders, Philadelphia, USA, 4th edition, 2000.

29. Normal vertebral artery & vein
V2
Vertebral artery & vein seen between vertebral processes of spine
Color Doppler Pulsed Doppler
Zwiebel WL. Introduction to vascular ultrasonography.
W.B. Saunders, Philadelphia, USA, 4th edition, 2000.

30. Subclavian artery
Mirror image below pleura
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
Color Doppler US Pulsed Doppler US
Normal triphasic waveform

31. 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

32. 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

33. Extracranial carotid artery & stroke
• Stroke is third leading cause of death in USA
• > 500.000 new cases of CVA reported annually
• 20 – 30% of stokes due to severe carotid artery stenosis
• Stenosis involves ICA within 2 cm of bifurcation
• CEA* more benefical than medical tt in symptomatic
or asymptomatic patients with > 70% carotid stenosis**
* CEA: Carotid endarterectomy
** NASCET: North American Symptomatic Carotid Endartectomy Trial
** ECST: European Carotid Surgery Trial

34. Common sites for extracranial arterial disease
Most common site at carotid bifurcation
with plaque extending into ICA
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.

35. Plaque characterization
Low Lipid – < SCM – Flow void
Moderate Collagen – Easy to see – > SCM
High with shadow Calcification – Focal or diffuse
 Echogenicity
Calcification: no correlation with neurologic symptoms
Focal hypoechoic zones: Hemorrhage – Necrosis – Lipid
 Heterogenous plaque
Common sources of cerebral emboli: TIA – Stroke
Poor US results for ulcer detection
 Plaque surface features

36. Appearance of atheromatous plaques
Homogeneous echolucent Homogeneous echogenic
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Heterogeneous plaque Cauliflower’ calcification

37. Calcified plaque
Calcific plaque with shadow
obscuring portion of the bulb
Interrogate artery beyond plaque
Shadowing segment < 1 cm
No turbulent flow: unsignificant stenosis
Damped or turbulent flow: tight stenosis
Shadowing segment > 2 cm
Degree of stenosis indeterminate
Other modalities recommended

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

39. Sources of error in ulcer diagnosis
Plaque surface irregular
but not ulcerated
Adjacent plaque
simulate ulceration
Image plan does not include
the ulcer
Zwiebel WL. Introduction to vascular ultrasonography.
W.B. Saunders, Philadelphia, USA, 4th edition, 2000.

40. Large plaque ulcer
Power Doppler
“eddy flow”
Color Doppler
Pseudo-dissection
Zwiebel WL. Introduction to vascular ultrasonography.
W.B. Saunders, Philadelphia, USA, 4th edition, 2000.

41. Ulcerated plaque or twinkle artifact
Scale 86 cm/sec, color in diastole
Color flow disappeared
Color artifact continues to twinkle
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
Hard plaque in proximal ICA
Questionable flow at plaque surface

42. Estimation of carotid stenosis
Diameter reduction Surface reduction

43. Relationship between diameter reduction
& cross-sectional area reduction
Diameter reduction
(%)
Cross-sectional area reduction
(%)
30 50
50 75
70 90

44. Cardinal Doppler parameter to grade stenosis
Best documented Doppler parameter for carotid stenosis
Peak Systolic Velocity (PSV)
Quite valuable for detecting high-grade carotid stenosis
End Diastolic Velocity (EDV)
Avoid errors of collateralization
Avoid errors of physiological factors:
BP – Pulse rate – Cardiac output – Peripheral resistance
PSV ratio

45. Relationship of flow, velocity & lumen size
Spencer MP & Reid JM. Stroke 1979 ; 10 : 326 – 330.

46. Grading stenosis – PSV ratio
Robbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.
Proximal: 2 cm proximal to carotid bulb
At stenosis: same Doppler angle if possible
Normal value < 2.0

47. Grant EG et al. Radiology 2003 ; 229 : 340 – 346.
17 authors:
1 Moderator
16 panelists
San Francisco, Calif
October 22–23, 2002

48. PSV, EDV & PSV ratio & degree of ICA stenosis
NASCET criteria
Grant EG et al. Radiology 2000 ; 214 : 247 – 252.
PSV & EDV ICA /CCA PSV

49. ICA stenosis on angiogram
ECST 2 (1998)
European Carotid Surgery Trial
(C – A / C) x 100
NASCET 1 (1991 – 1998)
North American Symptomatic Carotid Endartectomy Trial
(B – A / B) x 100
1 NASCET. N Engl J Med 1991 ; 325 : 445 – 453.

50. ICA stenosis on angiogram
Diameter reduction
* NASCET: North American Symptomatic Carotid Endartectomy Trial
** ECST: European Carotid Surgery Trial
30% 65%
40% 70%
50% 75%
60% 80%
70% 85%
80% 91%
90% 97%
* NASCET
(B – A / B) x 100
** ECST
(C – A / C) x 100

51. Degree of ICA Stenosis in Doppler US*
Consensus Criteria – NASCET criteria
ICA stenosis ICA PSV ICA EDV PSV ratio
(%) cm/sec cm/sec ICA/CCA
Normal < 125 < 40 < 2.0
< 50% < 125 < 40 < 2.0
50 – 69% 125 – 230 40 – 100 2.0 – 4.0
> 70% > 230 > 100 > 4.0
Near occlusion variable variable variable
Total occlusion undetectable undetectable not applicable
* Diameter reduction
Grant EG et al. Radiology 2003 ; 229 : 340 – 346.

52. Degree of ICA Stenosis in Doppler US*
Consensus Criteria – NASCET criteria
ICA stenosis ICA PSV ICA EDV PSV ratio
(%) cm/sec cm/sec ICA/CCA
Normal < 125 < 40 < 2.0
< 50% < 125 < 40 < 2.0
50 – 69% 125 – 230 40 – 100 2.0 – 4.0
> 70% > 230 > 100 > 4.0
Near occlusion variable variable variable
Total occlusion undetectable undetectable not applicable
* Diameter reduction
Grant EG et al. Radiology 2003 ; 229 : 340 – 346.

53. Aliasing or high velocity jet
Area of highest velocity in area of stenosis

54. Adjustment of color gain
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
Color gain at 80%
Marked turbulence of ICA & ECA
No luminal narrowing
Anatomy of bifurcation
demonstrated more accurately
Color gain at 66%

55. ICA stenosis
PSV 500 cm/sec
EDV 300 cm/sec
Spectral broadening
80% diameter stenosis

56. Color Doppler bruit
Extensive soft tissue color Doppler bruit surrounds
carotid bifurcation with 90% ICA stenosis
Confetti sign

57. Post-stenotic zone/ Immediately after stenosis
• Cannot be precisely quantified (evaluated visually)
Fill-in of spectral window > 50% diameter reduction
Severely disturbed flow > 70% diameter reduction
High amplitude & low frequency Doppler signal
Flow reversal
Poor definition of spectral border
• May be only sign of carotid stenosis in calcified plaque
Spectral broadening

58. Spectral broadening
Immediately after stenosis
High amplitude & low frequency Doppler signal
Poor definition of spectral border
Flow reversal
Severe spectral broadening: > 70% diameter reduction

59. Pseudo-spectral broadening
• High gain setting
• Vessel wall motion
• Tortuous vessels
• Site of branching
• Abrupt change in vessel diameter
• ↑ velocity: athlete - high cardiac output - AVF1 - AVM2
• Aneurysm, dissection, & FMD3
1AVF: Arterio-Venous Fistula
2AVM: Arterio-Venous Malformation
3FMD: Fibro-Muscular Dysplasia

60. Post-stenotic zone / Distal to site of stenosis
Rohren EM et al. Am J Roentgenol 2003 ; 181 : 1695 – 1704.
Tardus-parvus waveform

61. 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
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.

62. Tight stenosis or occlusion?
• Difficult to distinguish tight stenosis from occlusion
• Completely occluded ICA
Will not release emboli
Not corrected by surgery
• Very severe stenosis
Potential source for emboli or acute thrombosis
May require urgent surgery

63. Optimization of low flow velocities
• Decreased color velocity scale
• Increase color, power & pulsed Doppler gain
• Decreased wall filter
• Focal zone at level of diseased segment
• Doppler angle as low as possible (60° or less)
• Increased persistence
• Increase sample volume gate

64. Subtotal occlusion of ICA
“string sign” or “trickle flow ”
Narrow channel of low-velocity in subtotal ICA occlusion
Low PRF & low filter required to detect low-velocity flow

65. High grade “string sign” stenosis
Tardus-Parvus waveform
Tardus: Long rise time
Parvus: Low PSV

66. Endarterctomy without arteriography
• Arteriography Expensive
Risks: stroke (0.1 – 0.6%) – death (0.1%)
Rarely affect surgical plan
Sufficient information obtained with MRI
• Conditions Good experience of US department
Stenosis localized to carotid bifurcation
Unequivocal US findings
Symptoms ipsilateral to carotid stenosis
Zwiebel WL. Introduction to vascular ultrasonography.
W.B. Saunders, Philadelphia, USA, 4th edition, 2000.

67. 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
• Contro-lateral carotid stenosis
• Carotid dissection

68. Short & long stenosis of ICA
Robbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.
Zwiebel WJ et al. Ultrasound Quarterly 2005 ; 21 : 113 – 122.
Short stenosis (frequent) Long stenosis (rare)
PSV lower than expected
EDV maintained at high level
Can produce very high PSV
(> 500 cm/s)

69. Long stenosis of ICA
Zwiebel WJ et al. Ultrasound Quarterly 2005 ; 21 : 113 – 122.
RICA
RICA: PSV 183 cm/sec
EDV 105 cm/sec
CCA: PSV 76 cm/sec
PSV ratio: 2.4
Inconsistent data
Long stenosis of ICA > 70%

70. Occlusion of ICA
• Absence of flow by color, power & pulsed Doppler
• “Internalization” of ipsilateral ECA waveform
• Reversed flow in ICA or CCA proximal to occlusion
• Thrombus or plaque completely fills lumen of ICA
• Externalization of ipsilateral CCA or proximal ICA
• Higher velocities in controlateral CCA vs ipsilateral CCA

71. Occlusion of ICA
ICA
ECA
CCA
Retrograde flow in stump of ICA
Absence of flow in ICA beyond
Doppler spectrum from CCA
Externalization of CCA

72. Occlusion of ICA
“to-and-fro” flow or thud flow
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
Damped systolic flow
Reversed flow in early diastole
Pulsed Doppler of CCA

73. Internalization of ECA
Rohren EM et al. Am J Roentgenol 2003 ; 181 : 1695 – 1704.
Patient with complete occlusion of left ICA

74. 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

75. 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”

76. Occlusion of CCA
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
Absence of flow in distal CCA
Reversed flow in ECA
Normal flow in ICA
Internalization of ECA
Delayed systolic acceleration (tardus)
Positive temporal tap maneuver

77. Ectatic CCA
Ectatic CCA as it arises from inominate artery
Responsible for pulsatile right supra-clavicular mass

78. Schematic Doppler waveforms of VA

79. High-resistance flow in vertebral artery
High-resistance flow
No diastolic component
Robbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.
Distal VA stenosis or occlusion
Hypoplastic vertebral artery
Differential diagnosis:
Dizziness
Unsteady walking
Correlation with symptoms

80. Vertebral artery occlusion
V2
Black & white US Color Doppler
Zwiebel WL. Introduction to vascular ultrasonography.
W.B. Saunders, Philadelphia, USA, 4th edition, 2000.

81. Route of flow in left vertebral steal
Zwiebel WL. Introduction to vascular ultrasonography.
W.B. Saunders, Philadelphia, USA, 4th edition, 2000.

82. 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

83. 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.

84. Provocative maneuver in steal syndrome
Conversion of pre-steal waveform to more pronounced steal
following deflation of pressure cuff
* Inflation of pressure cuff greater than systolic arterial pressure on ipsilateral arm
Kliewer MA et al. Am J Roentgenol 2000 ; 174 ; 815 – 9.
Inflation of pressure cuff on arm for 3 min & rapid deflation*
Pre-steal More pronounced steal

85. 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.

86. 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

87. 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)

88. 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

89. Fibromuscular dysplasia
Middle 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

90. 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

91. 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
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

92. Dissection of aorta & cervical arteries
Patho-anatomy
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
Intimal rupture with false lumen
Open or secondarily thrombosed
Aorta
External intramural hematoma
Lumen constriction
Rare intimal rupture
Cervical

93. Spontaneous dissection of ICA
Asymmetric 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

94. 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

95. Thoracic aortic dissection
Stanford classification
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
Type B
Dissection of descending aortaDissection of ascending aorta
Possible continuation to supraaortic vessels
Type A

96. Dissection of common carotid artery
Stanford A
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
Transverse view Longitudinal view
Detection of two lumina & dissection membrane

97. 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

98. 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

99. 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.

100. Vasospasm
Janzarik WG et al. Stroke 2006 ; 37 : 2170 – 2173.
Severe narrowing of ICA No stenosis detected
4 days later

101. 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

102. Extra-cranial ICA aneurysms
Clevert DA et al. Clin Hemorheology Microcirculation 2008 ; 39 : 133 – 146.
Color Doppler US Power Doppler US
Uncomplete delineation of aneurysm – Thrombi could not be excluded
Difficult definition for extracranial carotid artery aneurysms
due to normal dilatation of bulb

103. ICA aneurysm / Parietal thrombosis
Terborg C et al. Ultraschall Med 2007 ; 28 : 216 – 218.
Aneurysm of proximal ICA
Parietal thrombus & homogeneous thickening of vessel wall
Longitudinal section Transversal section

104. CCA aneurysm / Rupture
Clevert DA et al. Clin Hemorheology Microcirculation 2008 ; 39 : 133 – 146.

105. CCA pseudoaneurysm / Rare
One month after bilateral neck dissection
Flor N et al. J Laryngol Otol 2007 ; 121 : 497 – 500.
CCA Pseudoaneurysm
Large connecting neck
Color Doppler US CE multidetector CT
CCA Pseudoaneurysm
Large connecting neck

106. 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

107. Arterio-venous fistula
Attempt to perform US-guided jugular catheter insertion
Clevert DA et al. Ultraschall Med 2010 ; 31 : 610 – 612.
Turbulent flow in fistula track High-velocity turbulent flow in track
Suspicion of communication between CCA & IJV
CCA
IJV

108. 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

109. 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
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

110. 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

111. Horton's arteritis / Giant cell arteritis
Concentric hypoechoic wall thickening
Superficial temporal artery
VA – Longitudinal view VA – Transverse view
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.

112. 1 sAUROC: Summary Area Under Receiver Operating Characteristic
2 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 arteritis
US as first-line investigation, biopsy if negative scan

113. 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

114. 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%

115. Carotid body tumor
Highly vascular mass in carotid bifurcation
Zwiebel WL. Introduction to vascular ultrasonography.
W.B. Saunders, Philadelphia, USA, 4th edition, 2000.

116. 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

117. 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
1 International Headache Society. Cephalalgia 1988 ; 8 (Suppl 7) : 1 – 96.
2 Kosaka N et al. Eur Radiol 2007 ; 17 : 2430 – 2433.

118. Idiopathic carotidynia
US findings comparable to dissection
Kosaka N et al. Eur Radiol 2007 ; 17 : 2430 – 2433.
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

119. Spontaneous dissection & carotidynia
Spontaneous dissection Carotidynia
Location Beyoud bifurcation At or near bifurcation
Thickening layers One 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.

120. 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

121. 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

122. 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

123. 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 retraction
Dicrotic notch
Found also with hypertrophic obstructive cardiomyopathy

124. Severe aortic regurgitation
Rohren EM et al. Am J Roentgenol 2003 ; 181 : 1695 – 1704.
Normal or elevated PSV followed by precipitous decline
Revered flow during diastole
Water-hammer spectral appearance
CCA

125. Aortic stenosis
Scoutta LM et al. Ultrasound Clin 2006 ; 1 : 133 – 159.
RCCA – Tardus-Parvus LCCA – Tardus-Parvus
RVA – Tardus-Parvus

126. Right inominate artery stenosis
RCCA – Tardus-Parvus LCCA – Normal waveform
RVA – Reversed flow
Scoutta LM et al. Ultrasound Clin 2006 ; 1 : 133 – 159.

127. Right inominate artery stenosis
Zwiebel WJ, Pellerito JS. Introduction to Vascular Ultrasonography.
5th ed. Philadelphia: Elsevier Saunders; 2005.
RICA : to-and-frow flow
RCCA : to-and-frow flow
RVA : reversed flow
RSCA : damped flow
Right carotid steal

128. 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
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
Arrhythmias can be real problem
Normal PSV in CCA (45 – 125 cm/sec)

129. 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
Abropoulos NL et al. Vasc Endovascular Surg 2007 ; 41 : 417 – 427.

130. References
Elsevier – 2005 Springer-Verlag – 2011
C. Arning et al. Ultraschall Med 2008 ; 31 : 576 – 599.

131. Thank You