This document discusses carotid Doppler ultrasound. It begins by outlining the anatomy of the carotid arteries and normal Doppler findings. It then discusses causes of carotid artery disease including atherosclerosis. Extra-carotid diseases that can affect the carotid arteries are also mentioned. The document provides detailed guidance on performing and interpreting carotid Doppler ultrasound scans including evaluating the intima-media thickness, flow patterns, spectral analysis, and grading stenosis. Imaging features of normal and diseased arteries are presented along with tips for accurate evaluation.
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.
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.
Doppler ultrasound of visceral arteriesSamir Haffar
Doppler ultrasound of different diseases of visceral arteries including arterial stenosis and occlusion, arterial aneurysm, artrial pseudoaneurysm, arterio-venous fistula, artrial dissection, and abdominal vascular compression syndromes
Fundamentals of Vascular Ultrasound.
Looking at the basics of carotid, lower extremity arterial, renal, celiac, SMA studies, as well as touching on venous insufficiency. Part I of series.
Role of medical imaging in management of arteriovenous fistula Dr. Muhammad B...Dr. Muhammad Bin Zulfiqar
This presentation is very helpful for vascular sergeons, interventional radiologists and sonographers that how to map Vasculature before construction of AV fistula for hemodialysis, how to check its patency, how to check its proper functioning ,to comment on its failure and decide when to reintervene.
Superb microvascular imaging A Sonographic Technical AdvanceDr. Muhammad Bin ...Dr. Muhammad Bin Zulfiqar
Superb microvascular imaging A Sonographic Technical AdvanceDr. Muhammad Bin Zulfiqar Services Institute of Medical Sciences / Services Hospital Lahore
Details about New Technical Advances in Sonography.
Doppler ultrasound of visceral arteriesSamir Haffar
Doppler ultrasound of different diseases of visceral arteries including arterial stenosis and occlusion, arterial aneurysm, artrial pseudoaneurysm, arterio-venous fistula, artrial dissection, and abdominal vascular compression syndromes
Fundamentals of Vascular Ultrasound.
Looking at the basics of carotid, lower extremity arterial, renal, celiac, SMA studies, as well as touching on venous insufficiency. Part I of series.
Role of medical imaging in management of arteriovenous fistula Dr. Muhammad B...Dr. Muhammad Bin Zulfiqar
This presentation is very helpful for vascular sergeons, interventional radiologists and sonographers that how to map Vasculature before construction of AV fistula for hemodialysis, how to check its patency, how to check its proper functioning ,to comment on its failure and decide when to reintervene.
Superb microvascular imaging A Sonographic Technical AdvanceDr. Muhammad Bin ...Dr. Muhammad Bin Zulfiqar
Superb microvascular imaging A Sonographic Technical AdvanceDr. Muhammad Bin Zulfiqar Services Institute of Medical Sciences / Services Hospital Lahore
Details about New Technical Advances in Sonography.
In this presentation we will discuss role of Doppler US in Infertility, fertilization and assisted fertilization.
we will discuss the favorable and unfavorable RI and PI.
We will discuss role of doppler us in various gynecological malignancies.
In this presentation we will discuss normal doppler parameters in portal and hepatic veins and hepatic artery. We will discuss the pathologies regarding hepatic, and portal veins and hepatic artery.
we will discuss Role of sonography in TIPS evaluation.
we will discuss the role of Doppler in post op follow up of hepatic transplant.
The principles of vascular repair with sutures were established in the first decade of the 20th century by Alexis Carrel, who in 1912 was awarded the Nobel Prize for medicine for his work .Since then, technical refinements of suture materials have made possible surgical reconstruction of most arteries from the root of the aorta to microvascular anastomosis or repair of the smallest vessels, e.g., digital arteries or those on the surface of the brain.
Most common type of birth defect
Defect in structure or function of the heart and great vessels
1 in 1000 live births
The incidence is higher in stillborns (3-4%), spontaneous abortuses (10-25%), and premature infants
About 1 in 4 babies born with a heart defect has a critical heart disease
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June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
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This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
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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. PART I
Anatomy of carotid arteries
Normal Doppler US of carotid arteries
Causes of carotid artery disease
•
Common Carotid Artery
•
Internal Carotid Artery
•
External carotid Artery
4. Extra cranial cerebral arteries
All arteries that carry blood from heart up to base of skull
Right & left sides of extra cranial circulation not symmetrical
6. 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
7. Vertebral artery course
BA
V4
V3
V2
V1
V0
VAs asymmetric in 75 % – Left dominant in 80 %
Posteriorly directed loop when exists C1 transverse process
2 VAs units to form basilar artery: collateralization
8. 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
9. All carotid artery examinations should be
performed with:
• Gray-scale US
• Color Doppler
• Power Doppler
• Spectral Doppler
Integrate gray scale, color flow, & spectral findings
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
10. Position for scanning the carotid arteries
Patient lie down in supine or semisupine position
Head hyperextended & rotated 45° away from side being examined
Higher-frequency linear transducers (≥ 7.5 MHz)
11. 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
16. 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
17. Internal & external carotid artery
Power Doppler US
2 small branches originating from ECA
19. Typical normal Doppler spectra
Internal carotid artery
PSV: 45 – 125 cm/sec
Difference between 2 sides < 15 cm/sec
External carotid artery
Common carotid artery
20. Dicrotic notch
Normal feature
Closure of aortic valve with temporary cessation of forward flow
Resumption of forward flow by elastic rebound of aortic wall
22. Abnormal Doppler flow in tortuous vessel
Tortuosity can increase velocity, although there is no stenosis
Tortuous CCA displays color
High velocity due to eccentric
Doppler eccentric jets of flow
jet in tortuous CCA
Try sampling just beyond the curve
23. Temporal tapping of ECA
“Saw-tooth” appearance
Small regular deflections (TT)
Frequency corresponds to rate of temporal tapping
Deflections best seen during diastole
24. Differentiation between ICA & ECA
Features
Size
Branches
Orientation
Pulsed Doppler
Temporal tap
ICA
ECA
Usually larger
Usually smaller
Rarely
Yes
Posterior
Anterior
Low resistance
High resistance
Usually negative
Usually positive
25. Protocol for VA examination
Longitudinal VA between transverse processes
– Direction of flow
– Waveform configuration
– Measure PSV
Caudad survey
– Follow artery cauded to its origin
Cephalad survey
– Follow artery cephalad above transverse processes
26. Ultrasound of normal vertebral vessels
Vertebral artery
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 vein
May occasionally be seen adjacent to VA
Flow caudad & nonpulsatile
30. 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
31. Causes of carotid artery diseases
Arteriosclerotic disease
Most common cause
Non-arteriosclerotic diseases
Fibro muscular dysplasia
Dissection
Vasospasm
Aneurysm & pseudo aneurysm
Arterio-venous fistula
Arteritis: Takayasu – Horton
Carotid body tumor
Idiopathic carotidynia
32. 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 beneficial than medical tm in symptomatic
or asymptomatic patients with > 70% carotid
stenosis**
* CEA: Carotid endarterectomy
** NASCET: North American Symptomatic Carotid Endartectomy Trial
** ECST: European Carotid Surgery Trial
33. Common sites for extracranial arterial disease
Most common site at carotid bifurcation
with plaque extending into ICA
34. Plaque characterization
Echogenicity
Low
Lipid – Flow void
Moderate
High with shadow
Collagen – Easy to see
Calcification – Focal or diffuse
Heterogenous plaque
Calcification: no correlation with neurologic symptoms
Focal hypoechoic zones: Hemorrhage – Necrosis – Lipid
Plaque surface features
Common sources of cerebral emboli: TIA – Stroke
Poor US results for ulcer detection
36. Calcified plaque
Interrogate artery beyond plaque
Shadowing segment < 1 cm
No turbulent flow: insignificant stenosis
Damped or turbulent flow: tight stenosis
Shadowing segment > 2 cm
Degree of stenosis indeterminate
Other modalities recommended
Calcific plaque with shadow
obscuring portion of the bulb
38. Sources of error in ulcer diagnosis
Image plan does not include
the ulcer
Adjacent plaque
simulate ulceration
Plaque surface irregular
but not ulcerated
40. Ulcerated plaque or twinkle artifact
Hard plaque in proximal ICA
Questionable flow at plaque surface
Scale 86 cm/sec, color in diastole
Color flow disappeared
Color artifact continues to twinkle
47. ICA stenosis on angiogram
NASCET 1 (1991 – 1998)
North American Symptomatic Carotid Endartectomy Trial
(B – A / B) x 100
ECST 2 (1998)
European Carotid Surgery Trial
(C – A / C) x 100
1 NASCET.
N Engl J Med 1991 ; 325 : 445 – 453.
48. ICA stenosis on angiogram
Diameter reduction
* NASCET
(B – A / B) x 100
** ECST
(C – A / C) x 100
30%
40%
65%
70%
50%
75%
60%
80%
70%
85%
80%
91%
90%
97%
* NASCET: North American Symptomatic Carotid Endartectomy Trial
** ECST: European Carotid Surgery Trial
51. Aliasing or high velocity jet
Area of highest velocity in area of stenosis
52. Adjustment of color gain
Color gain at 80%
Color gain at 66%
Marked turbulence of ICA & ECA
No luminal narrowing
Anatomy of bifurcation
demonstrated more accurately
54. Color Doppler bruit
Extensive soft tissue color Doppler bruit surrounds
carotid bifurcation with 90% ICA stenosis
Confetti sign
55. Post stenotic zone/ Immediately after stenosis
Spectral broadening
• 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
56. Spectral broadening
Immediately after stenosis
High amplitude & low frequency Doppler signal
Poor definition of spectral border
Flow reversal
Severe spectral broadening: > 70% diameter reduction
57. 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:
2AVM:
3FMD:
Arterio-Venous Fistula
Arterio-Venous Malformation
Fibro-Muscular Dysplasia
59. 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
60. 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
61. 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
62. 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
63. High grade “string sign” stenosis
Tardus Parvus waveform
Tardus: Long rise time
Parvus: Low PSV
64. Endarterectomy 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
65. 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
66. Short & long stenosis of ICA
Short stenosis (frequent)
Long stenosis (rare)
Can produce very high PSV
PSV lower than expected
(> 500 cm/s)
EDV maintained at high level
67. Long stenosis of ICA
RICA:
CCA:
PSV ratio:
RICA
PSV
183 cm/sec
EDV
105 cm/sec
PSV
76 cm/sec
2.4
Inconsistent data
Long stenosis of ICA > 70%
Zwiebel WJ et al. Ultrasound Quarterly 2005 ; 21 : 113 – 122.
68. 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 contralateral CCA vs. ipsilateral CCA
70. Occlusion of ICA
“to-and-fro” flow or thud flow
Pulsed Doppler of CCA
Damped systolic flow
Reversed flow in early diastole
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
72. 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.
73. 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.
CCA, which has no branches, divides into the internal and external carotid arteries.Carotid artery widens at the level of the bifurcation to form the carotid bulb & degree of widening of carotid bulb is quite variable.Level of the carotid bifurcation in the neck is highly variable.Proximal branches of the ECA are the superior thyroid, lingual, facial and maxillary arteries.Vertebral artery is the first branch of the subclavian artery, arising from the highest point of the subclavian arch. At the sixth cervical vertebra, the vertebral artery runs posteriorly to travel upward through the transverse foramen of cervical vertebrae.Two vertebral arteries join, at the base of the skull, to form basilar artery, which then divides to form posterior cerebral arteries.
Tortuosity can cause apparent velocity increase even although there is no stenosis. This is due to difficulty in obtaining a correct insonating angle, non-linear or helical flow, or increased velocityon the inside of the curve. Try sampling just beyond the curve.
“Saw-tooth” appearance: مظهر أسنان المنشار
Endarterectomy decrease the risk of ipsi-lateral hemispheric stroke or death by 53 to 84% as compared to medical treatment.
Cauliflower: قرنبيط
Eddy: دوامة
A panel of experts from a variety of medical specialties was convened under the auspices of the Society of Radiologists in Ultrasound to arrive at a consensus about the performance of Doppler ultrasonography (US) to aid in diagnosis of internal carotid artery (ICA)stenosis. The panel met in San Francisco, Calif, October 22–23, 2002, and drew up a consensus statement. Although there are several facets of carotid disease that could be considered by such a panel, carotid stenosis (and by extension, carotid occlusion) is by far the most common pathologic process involving carotid arteries.The panel consisted of a moderator and 16 panelists from various medical specialties.
the method used to report the degree of narrowing from an angiogram differed between the European and North American trials.In the ECST trial, the degree of stenosis was measured by comparing the residual lumen diameter with the estimated diameter of the carotid bulb, whereas the NASCET trial compared the residual lumen diameter with the diameter of the normal distal ICA.
In the North American Symptomatic Carotid Endartectomy Trial, the narrowest portion of the vascular lumen was compared with the “normalized lumen distally”.In the European Symptomatic Carotid Trial study and studies performed prior to the NASCET study, the degree of stenosis was determined by comparing the narrowest diameter of the residual lumen to an estimate of the original lumen in the same area. Because the original lumen cannot be depicted on the angiogram, exact measurement is impossible.The panel recommended that the NASCET method of carotid stenosis measurement should be employed when angiography is used to correlate the US findings. While the NASCET method of measurement may not reflect the burden of atherosclerosis in the proximal ICA, it does minimize the amount of interobserver variability.
Stringsign stenosis(Figure 15a. Circumferential calcified plaque in the proximal ICA. (a) PW Doppler image of the right ICA obtained immediately distal to a circumferential shadowing plaque shows no sign of turbulence, and the PSV is within normal limits. Therefore, there is unlikely to be a significant stenosis behind the calcified plaque. (b) PW Doppler image of the proximal right ICA shows a tardus-parvus waveform. A severe proximal stenosis behind the shadowing plaque is suspected; therefore, evaluation with another imaging modality is required. (c) PW Doppler image of the right ICA shows spectral broadening (turbulence) with an elevated PSV. These results may be due to a high degree of stenosis immediately proximal to the point of sampling; therefore, further investigation with another imaging modality is required. )
Long stenosis: > 2 cm
It can be difficult to distinguish tight stenosis from occlusion. A completely occluded ICA cannot be corrected by surgery and will not release emboli. However, very severe stenosis can be a potential source for emboli or acute thrombosis and may require urgent surgery.
Thud: صوت مكتوم
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.