5. Occlusion of CCA
Reversed flow from ECA
to supply ICA & brain
“ECA-to-ICA collateralization”
Robbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.
6. Occlusion of CCA
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
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
7. Ectatic CCA
Ectatic CCA as it arises from innominate artery
Responsible for pulsatile right supra-clavicular mass
12. Types of subclavian steal
Pre-steal or bunny waveform
Transient reversal of vertebral flow during systole
Converted to partial or complete by provocative
maneuver
Incomplete steal
Striking deceleration of velocity in mid or late systole
High-grade stenosis of subclavian rather than occlusion
Complete steal
Complete reversal of flow within vertebral artery
14. Provocative maneuver in steal syndrome
Inflation of pressure cuff on arm for 3 min & rapid deflation*
Pre-steal
More pronounced steal
Conversion of pre-steal waveform to more pronounced steal
following deflation of pressure cuff
15. 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.
16. 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
17. 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)
18. 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
19. Fibromuscular dysplasia
Middle age women – Renal arteries – String of beads pattern
ICA
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.
20. Causes of carotid artery diseases
Arteriosclerotic disease
Most common cause
Non-arteriosclerotic diseases
Fibromuscular dysplasia
Dissection
Vasospasm
Aneurysm & pseudoaneurysm
Arterio-venous fistula
Arteritis: Takayasu – Horton
Carotid body tumor
Idiopathic carotidynia
21. Carotid & vertebral dissection
• Spontaneous dissection Bleeding from vasa vasorum
Most common ICA & VA (atlas loop)
Intramural hematoma
Pain – Stenosis – Horner
• Vascular injury
• Stanford A dissection
Iatrogenic: puncture – surgery
CCA
Intramural hematoma ± intimal tear
Intimal rupture in ascending aorta
CCA
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
22. Dissection of aorta & cervical arteries
Patho-anatomy
Aorta
Intimal rupture with false lumen
Open or secondarily thrombosed
Cervical
External intramural hematoma
Lumen constriction
Rare intimal rupture
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
23. 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
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
24. Spontaneous dissection of VA
Wall hematoma in V1
Double lumen in V2
Diagnostic criteria (one sufficient):
Intramural hematoma (asymmetric, not concentric)
Intimal rupture/double lumen (rare)
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
25. Thoracic aortic dissection
Type A
Stanford classification
Dissection of ascending aorta
Possible continuation to supraaortic vessels
Type B
Dissection of descending aorta
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
26. Dissection of common carotid artery
Stanford A
Transverse view
Longitudinal view
Detection of two lumina & dissection membrane
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
27. Dissection of CCA / Stenosis
Residuum after end of aortic dissection
Doppler of true lumen
Stenosis of true lumen
Doppler of false lumen
Enlargement of false lumen
before cranial end
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
28. Causes of carotid artery diseases
Arteriosclerotic disease
Most common cause
Non-arteriosclerotic diseases
Fibromuscular dysplasia
Dissection
Vasospasm
Aneurysm & pseudoaneurysm
Arterio-venous fistula
Arteritis: Takayasu – Horton
Carotid body tumor
Idiopathic carotidynia
29. Vasospasm
• Causes
idiopat
Migraine, eclampsia, vasculitis, drug abuse,
• Incidence Rarely identified (short duration)
Occur frequently & remain undetected
• Symptoms Cerebral or ocular ischemia
• US
• Dd
Direct &/or indirect signs of severe stenosis
Far above bifurcation – Sometimes bilateral
Complete regression in hours to days – Relapse
Dissection: wall hematoma – regression in weeks
• Treatment Calcium antagonists
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
31. Causes of carotid artery diseases
Arteriosclerotic disease
Most common cause
Non-arteriosclerotic diseases
Fibromuscular dysplasia
Dissection
Vasospasm
Aneurysm & pseudoaneurysm
Arterio-venous fistula
Arteritis: Takayasu – Horton
Carotid body tumor
Idiopathic carotidynia
32. 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
34. CCA aneurysm / Rupture
Clevert DA et al. Clin Hemorheology Microcirculation 2008 ; 39 : 133 – 146.
35. CCA pseudoaneurysm / Rare
One month after bilateral neck dissection
Color Doppler US
CCA Pseudoaneurysm
Large connecting neck
CE multidetector CT
CCA Pseudoaneurysm
Large connecting neck
Flor N et al. J Laryngol Otol 2007 ; 121 : 497 – 500.
36. Causes of carotid artery diseases
Arteriosclerotic disease
Most common cause
Non-arteriosclerotic diseases
Fibro muscular dysplasia
Dissection
Vasospasm
Aneurysm & pseudoaneurysm
Arterio-venous fistula
Arteritis: Takayasu – Horton
Carotid body tumor
Idiopathic carotidynia
37. Arterio-venous fistula
Attempt to perform US-guided jugular catheter insertion
IJV
CCA
Suspicion of communication between CCA & IJV
Turbulent flow in fistula track
High-velocity turbulent flow in track
38. Causes of carotid artery diseases
Arteriosclerotic disease
Most common cause
Non-arteriosclerotic diseases
Fibro muscular dysplasia
Dissection
Vasospasm
Aneurysm & pseudoaneurysm
Arterio-venous fistula
Arteritis: Takayasu – Horton
Carotid body tumor
Idiopathic carotidynia
39. 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.
40. Takayasu’s arteritis
Young female – SCA [‘pulseless’ disease] – CCA
CCA
Long hypoechoic wall thickening
Visualized in color Doppler as dark halo around vascular lumen
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
41. 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.
42. 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
1 sAUROC:
Summary Area Under Receiver Operating Characteristic
2 DOR: Diagnostic Odds Ratio
Ball EL et al. Br J Surg 2010 ; 97 : 1765 – 1771.
43. Causes of carotid artery diseases
Arteriosclerotic disease
Most common cause
Non-arteriosclerotic diseases
Fibromuscular dysplasia
Dissection
Vasospasm
Aneurysm & pseudoaneurysm
Arterio-venous fistula
Arteritis: Takayasu – Horton
Carotid body tumor
Idiopathic carotidynia
44. 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%
45. Carotid body tumor
Highly vascular mass in carotid bifurcation
Zwiebel WL. Introduction to vascular ultrasonography.
W.B. Saunders, Philadelphia, USA, 4th edition, 2000.
46. Causes of carotid artery diseases
Arteriosclerotic disease
Most common cause
Non-arteriosclerotic diseases
Fibromuscular dysplasia
Dissection
Vasospasm
Aneurysm & pseudoaneurysm
Arterio-venous fistula
Arteritis: Takayasu – Horton
Carotid body tumor
Idiopathic carotidynia
47. 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
2
Headache Society. Cephalalgia 1988 ; 8 (Suppl 7) : 1 – 96.
Kosaka N et al. Eur Radiol 2007 ; 17 : 2430 – 2433.
48. Idiopathic carotidynia
US findings comparable to dissection
US of distal CCA
Hypo-echoic soft tissue
around carotid artery
CE T1-weighted MRI
Enhanced tissue
around carotid artery
Three months later
Resolution of abnormal
soft tissue
Kosaka N et al. Eur Radiol 2007 ; 17 : 2430 – 2433.
49. 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
CAs
Native enhancement Enhancement after
In unclear cases, MRI enables differentiation
Arning C et al. Ultraschall Med 2008 ; 29 : 576 – 599.
50. 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
51. 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
52. Idiopathic dilated cardiomyopathy
Pulsus alternans
PSV oscillating between two levels on sequential beats
Cardiac rhythm remains regular throughout
Rohren EM et al. Am J Roentgenol 2003 ; 181 : 1695 – 1704.
53. Aortic regurgitation
Bisferious waveform [“beat twice” in Latin]
Two systolic peaks separated by midsystolic retraction
Dicrotic notch
Found also with hypertrophic obstructive cardiomyopathy
Kallman CE et al. Am J Roentgenol 1991 ; 157 : 403 – 407.
Rohren EM et al. AJR 2003 ; 181 : 169 5– 1704.
54. Severe aortic regurgitation
Water-hammer spectral appearance
CCA
Normal or elevated PSV followed by precipitous decline
Revered flow during diastole
Rohren EM et al. Am J Roentgenol 2003 ; 181 : 1695 – 1704.
58. Normal PSV in CCA (45 – 125 cm/sec)
High flow > 125 cm/sec in both CCAs
High cardiac output:
Hypertensive patients
Young athletes
Low flow < 45 cm/sec in both CCAs
Poor cardiac output:
Cardiomyopathies
Valvular heart disease
Extensive myocardial
infarction Arrhythmias can be real problem
59. Stenosis of intra-cranial ICA
High resistance waveform
ICA
High-grade stenosis distally (intracranial ICA)
Major occlusive lesions of cerebral arteries (MCA, ACA)
Massive spasm of cerebral arteries from intracranial hemorrhage
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.
Each diamond corresponds to a study estimate of sensitivity and specificity.Area of each diamond is proportional to the study sizeThe upper and lower curves represent the 95 per cent confidence intervals of the diagnostic odds ratio in the equation of curve.The presence of any of the markers of vascular inflammation (halo, stenosis, occlusion), compared with halo alone, seemed to improve sensitivity, while retaining specificity, although there was significant between-study heterogeneity (I2 = 81·7 per cent, P < 0·001).
“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.
Pulsusbisferiens, 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 hypertophicobstructive cardiomyopathy.Mechanism of pulsusbisferiens 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.
