Radiological anatomy of the Carotid arteries

C.N.SC.N.S..
Carotid arteriesCarotid arteries

Dr.Mohamed Ashraf Zaitoun, MD
Interventional Radiology Consultant, Zagazig University
Hospitals, Egypt
FINR-Switzerland
zaitoun82@gmail.com
www.zaitounclinic.com

DedicationDedication
To the memory of my late father, Prof Ashraf ZaitounTo the memory of my late father, Prof Ashraf Zaitoun
Interventional
Radiology Unit,
Zagazig University,
Egypt

Carotid arteries imagingCarotid arteries imaging
U.SU.S..
Conventional AngiographyConventional Angiography
C.TC.T..
C.T.AC.T.A..
M.R.IM.R.I..
M.R.AM.R.A..
DupplexDupplex
Radionuclide cerebral angiographyRadionuclide cerebral angiography
Plain x-raysPlain x-rays

11--U.SU.S..
Used in assessment of inner wall of vesselsUsed in assessment of inner wall of vessels
))normally smoothnormally smooth((
CCA & its bifurcation imaged by superficial probeCCA & its bifurcation imaged by superficial probe
( 7.5 MHZ( 7.5 MHZ((
Carotid sinus at bifurcation of CCACarotid sinus at bifurcation of CCA

22--Conventional AngiographyConventional Angiography
See laterSee later
33--C.TC.T..
--Done after injection of a radio-opaque substance to visualizeDone after injection of a radio-opaque substance to visualize
carotid system , cerebral arteries & choroid plexuscarotid system , cerebral arteries & choroid plexus
--At the level of circle of Willis arteries may be seenAt the level of circle of Willis arteries may be seen::
Ant. Cerebral arteryAnt. Cerebral artery
Post. CommunicatingPost. Communicating
Middle cerebralMiddle cerebral

44--M.R.IM.R.I..
Symmetry between the 2 sides should be evidentSymmetry between the 2 sides should be evident
normallynormally
55--C.T.A. & 6- M.R.AC.T.A. & 6- M.R.A..
See physicsSee physics

77--Radionuclide cerebral angiographyRadionuclide cerebral angiography
See isotopeSee isotope
88--DupplexDupplex
Detect stenosis , atheromatous plaques ,Detect stenosis , atheromatous plaques ,
thrombosisthrombosis……..

99--Plain x-raysPlain x-rays
Not visible unless calcified >> commonly in theNot visible unless calcified >> commonly in the
carotid siphon near the pituitary fossacarotid siphon near the pituitary fossa

Carotid AngiographyCarotid Angiography
DefDef..
IndicationsIndications
C.IC.I..
EquipmentEquipment
C.MC.M..
PreparationPreparation
MedicationsMedications
MethodsMethods
TechniqueTechnique
After careAfter care
ComplicationsComplications
How to avoid complicationsHow to avoid complications

**DefDef..
Injection of C.M. into the main arteries supplyingInjection of C.M. into the main arteries supplying
the brain to visualize the arterial supply ,the brain to visualize the arterial supply ,
capillary , venous & sinus drainage of the braincapillary , venous & sinus drainage of the brain

**IndicationsIndications
11--Intracerebral & S.A.H. ( in the investigation of suspectedIntracerebral & S.A.H. ( in the investigation of suspected
intraccranial aneurysms & AVMintraccranial aneurysms & AVM((
22--aneurysms presenting as space occuping lesionaneurysms presenting as space occuping lesion
33--cavernous sinus syndromecavernous sinus syndrome
44--Carotico-cavernous fistulaCarotico-cavernous fistula
55--Cerebral ischemia both of extra-cranial & intra-cranial originCerebral ischemia both of extra-cranial & intra-cranial origin
66--Preoperative assessment of cerebral tumorsPreoperative assessment of cerebral tumors
77--Suspected venous sinus thrombosisSuspected venous sinus thrombosis
88--Interventional procedures ( as embolizationInterventional procedures ( as embolization((

**C.IC.I..
11--Patient with unstable neurology ( usuallyPatient with unstable neurology ( usually
following SAH or strokefollowing SAH or stroke((
22--Patient unsuitable for surgeryPatient unsuitable for surgery
33--Patients whom vascular access would bePatients whom vascular access would be
impossible or excessively riskyimpossible or excessively risky

**EquipmentEquipment
11--Fluoroscopy unit or digital equipment with DSAFluoroscopy unit or digital equipment with DSA
facilitiesfacilities
22--Pump injectorPump injector
33--Catheter >> head hunter side winderCatheter >> head hunter side winder

**C.MC.M..
AngiographinAngiographin
6-106-10ml / injection in 1.5ml / injection in 1.5 –– 2 seconds2 seconds

**PreparationPreparation
--Clear explanation should be given together with aClear explanation should be given together with a
fair presentation of the risks and benefitsfair presentation of the risks and benefits
--Most patients can be examined using mild oralMost patients can be examined using mild oral
sedation ( e.g. 5-10 ml diazepamsedation ( e.g. 5-10 ml diazepam((
--Fasting 6 hrs before examFasting 6 hrs before exam
--Removal of any radio-opaque objectsRemoval of any radio-opaque objects
))dentures , hair pinsdentures , hair pins((

**MedicationsMedications
--With local anaesthesia >> sedativeWith local anaesthesia >> sedative
--Children & inco-operative patients >> generalChildren & inco-operative patients >> general
anaesthesiaanaesthesia

**MethodsMethods
))A) Indirect ( used in clinical practiseA) Indirect ( used in clinical practise((
))B) Direct ( not the routineB) Direct ( not the routine((

<<<<Indirect method ( percutaneous femoral arteryIndirect method ( percutaneous femoral artery
cathetercatheter((
--Selective carotid and vertebral injection using :Selective carotid and vertebral injection using :
head hunter , side winderhead hunter , side winder
Pig tail >>> aortogramPig tail >>> aortogram
--AdvantagesAdvantages
11--Selective & super selective injections areSelective & super selective injections are
possible from one arterial puncturepossible from one arterial puncture

22--Position of catheter tip is easily maintainedPosition of catheter tip is easily maintained
33--Easier radiographic positioningEasier radiographic positioning
44--Can be done with local anaesthesiaCan be done with local anaesthesia
55--Reduced radiation dose to radiologistReduced radiation dose to radiologist’’s handss hands
being manipulating catheters at groin regionbeing manipulating catheters at groin region

**DisadvantagesDisadvantages::
11--More sophisticated equipments & expensiveMore sophisticated equipments & expensive
materials requiredmaterials required
22--Difficult techniques in older patients withDifficult techniques in older patients with
tortous & atheromatous arteriestortous & atheromatous arteries

<<<<Direct puncture of carotid or vertebral arteriesDirect puncture of carotid or vertebral arteries::
**The carotid artery is punctured using needle &The carotid artery is punctured using needle &
cannulacannula
**AdvantagesAdvantages::
Not technically difficultNot technically difficult

**DisadvantagesDisadvantages::
11--Separate puncture is needed for each vesselSeparate puncture is needed for each vessel
22--Selective injection is difficultSelective injection is difficult
33--Proximal portion of arteries is not visualizedProximal portion of arteries is not visualized
44--Vascular damageVascular damage
55--HornerHorner’’s syndrome due to injury to sympathetics syndrome due to injury to sympathetic
chainchain

66--Dislodgment of atheromatous plaque byDislodgment of atheromatous plaque by
pressure on carotid sinuspressure on carotid sinus..
77--Bradycardia & hypotension caused by pressureBradycardia & hypotension caused by pressure
on carotid sinuson carotid sinus..
88--Needle tip may be dislodged easilyNeedle tip may be dislodged easily..
99--Vertebral artery may be narrow enough toVertebral artery may be narrow enough to
accommodate the needleaccommodate the needle..
1010--RadiologistRadiologist’’s hand are near primary beams hand are near primary beam..

**TechniqueTechnique::
11--SeldengerSeldenger’’s techniques technique<<<<
see vascularsee vascular
22--AortographyAortography
Extra-cerebral vesselsExtra-cerebral vessels
Intra-cerebral vesselsIntra-cerebral vessels

<<AortographyAortography
<<Extra-cerebral vesselsExtra-cerebral vessels::
--Examined in patients with ischemic C.V.S. toExamined in patients with ischemic C.V.S. to
detect possible source of emboli as followsdetect possible source of emboli as follows::
**RT & LT subclavian arteriesRT & LT subclavian arteries::
To include origin of RT vertebral arteryTo include origin of RT vertebral artery
**RT * LT CCAsRT * LT CCAs::
To detect small atheroma or stenotic segmentTo detect small atheroma or stenotic segment

<<Intra-cerebral arteriesIntra-cerebral arteries::
Both ICAs & one vertebral artery areBoth ICAs & one vertebral artery are
catheterizedcatheterized??
As injection of one vertebral artery is sufficient forAs injection of one vertebral artery is sufficient for
opacification of basilar artery & its branchesopacification of basilar artery & its branches..

Vertebral arteryVertebral artery

**FilmsFilms::
--ViewsViews<<<<
**Routine :A.P. & LateralRoutine :A.P. & Lateral
**Additional filmsAdditional films::
11--For aneurysm >> oblique viewsFor aneurysm >> oblique views
22--For SSS >> well seen on lateral viewFor SSS >> well seen on lateral view
But narrowing or occlusion is confirmed withBut narrowing or occlusion is confirmed with::
2020degrees + head rotated 10 degrees away from side of injection >> to separatedegrees + head rotated 10 degrees away from side of injection >> to separate
ant. & post. Ends of the sinusant. & post. Ends of the sinus..
33--For patency of ACA >> cross compression viewFor patency of ACA >> cross compression view
Carotid injection is done while other carotid is compressed in the neckCarotid injection is done while other carotid is compressed in the neck
<<<<if contrast flows into the arteries of both hemispheresif contrast flows into the arteries of both hemispheres==
Patency of the arteryPatency of the artery

--Hard copy films are taken from substraction unitHard copy films are taken from substraction unit
to demonstrate : phasesto demonstrate : phases
Arterial Capillary VenousArterial Capillary Venous

**After careAfter care::
As usual + observation of facial movementsAs usual + observation of facial movements
&&motor powermotor power..

**ComplicationsComplications::
General complications of catheter technique plusGeneral complications of catheter technique plus
<<
11--Increase incidence of cerebral embolusIncrease incidence of cerebral embolus
22--Transient cortical blindness may occur afterTransient cortical blindness may occur after
injection into vertebral vesselsinjection into vertebral vessels
33--Arterial spasm: due to crude manipulation ,Arterial spasm: due to crude manipulation ,
injury to vessels wallinjury to vessels wall

44--Hematoma formation in the neckHematoma formation in the neck
55--Focal neurological damageFocal neurological damage
66--Sensitivity to C.MSensitivity to C.M..
77--Incase of increase I.C.T. : symptoms areIncase of increase I.C.T. : symptoms are
aggrevated by angiography ( increase ICTaggrevated by angiography ( increase ICT((
88--Headache : behind the eye during injection inHeadache : behind the eye during injection in
carotid angiographycarotid angiography

**How to avoid complicationsHow to avoid complications::
11--Avoid air bubblesAvoid air bubbles
22--Avoid contamination from glove powder & dried blood or clotAvoid contamination from glove powder & dried blood or clot
on gloveson gloves
33--Avoid contamination of saline or C.MAvoid contamination of saline or C.M..
44--Avoid exposure of solution to airAvoid exposure of solution to air
55--C.M. or heaprin/saline in an open bowle is bad practiseC.M. or heaprin/saline in an open bowle is bad practise
66--Never pass a catheter or guide wire through a vessel that hasnotNever pass a catheter or guide wire through a vessel that hasnot
been visualized by preliminary injection of C.Mbeen visualized by preliminary injection of C.M..
77--Use appropriate guide wires : if there is resistance to passage ofUse appropriate guide wires : if there is resistance to passage of
standard wire , use a more flexible wirestandard wire , use a more flexible wire
88--In sharp curves >> use micro-cathetersIn sharp curves >> use micro-catheters

Transcranial U/STranscranial U/S
--Ultrasound is a fast and bedside examinationUltrasound is a fast and bedside examination
which makes it ideal for premature infantswhich makes it ideal for premature infants
--Generally the large fontanel is used as acousticGenerally the large fontanel is used as acoustic
windowwindow
-The small fontanel however is a good window-The small fontanel however is a good window
to the occipital lobesto the occipital lobes

**LimitationsLimitations::
11--Limited overview in posterior fossa andLimited overview in posterior fossa and
convexity of the brainconvexity of the brain
22--Absence of US-signs in ischemia in full-terms inAbsence of US-signs in ischemia in full-terms in
first 24 hoursfirst 24 hours
33--Difficulty in detecting migration disorders,Difficulty in detecting migration disorders,
cortical dysplasiacortical dysplasia

**Uses : in premature infantsUses : in premature infants
11--Peri Ventricular Leukomalacia ( PVLPeri Ventricular Leukomalacia ( PVL((
also known as Hypoxic-Ischemicalso known as Hypoxic-Ischemic
Encephalopathy (HIE) of the pretermEncephalopathy (HIE) of the preterm
22--Intracrnial hemorrhageIntracrnial hemorrhage
33--HydrocephalusHydrocephalus

Up to 40 weeks of gestational age the Levene-indexUp to 40 weeks of gestational age the Levene-index
should be used and after 40 weeks the ventricular indexshould be used and after 40 weeks the ventricular index..
The Levene index is the absolute distance between theThe Levene index is the absolute distance between the
falx and the lateral wall of the anterior horn in thefalx and the lateral wall of the anterior horn in the
coronal plane at the level of the third ventriclecoronal plane at the level of the third ventricle..
This is performed for the left and right sideThis is performed for the left and right side..
These measurements can be compared to the referenceThese measurements can be compared to the reference
curve and are quite usefull for further follow-upcurve and are quite usefull for further follow-up

After 40 weeks the ventricular index or frontalAfter 40 weeks the ventricular index or frontal
horn ratio should be used, i.e. the ratio of thehorn ratio should be used, i.e. the ratio of the
distance between the lateral sides of thedistance between the lateral sides of the
ventricles and the biparietal diameterventricles and the biparietal diameter
When using this ratio you have to realise, thatWhen using this ratio you have to realise, that
when the ventricular system widens, the frontalwhen the ventricular system widens, the frontal
horns tend to enlarge in the craniocaudalhorns tend to enlarge in the craniocaudal
direction more than in the left to rightdirection more than in the left to right
dimensiondimension

Transcranial Doppler U/STranscranial Doppler U/S
--Transcranial Doppler ultrasound (TCD) is a non-invasiveTranscranial Doppler ultrasound (TCD) is a non-invasive
modality for imaging blood flow in cerebral arteriesmodality for imaging blood flow in cerebral arteries
and veins ( B-mode , colour & pulsed Dopplerand veins ( B-mode , colour & pulsed Doppler((
--In TCD, ultrasonic waves are generated by a probeIn TCD, ultrasonic waves are generated by a probe
placed over the skull. The bony plate of the skull limitsplaced over the skull. The bony plate of the skull limits
TCD measurements to 3 primary sites (or acousticTCD measurements to 3 primary sites (or acoustic
windowswindows(:(:
11((the temporal bone along the orbitomeatal linethe temporal bone along the orbitomeatal line
22((the foramen magnum at the base of the skullthe foramen magnum at the base of the skull
33((the optic foraminathe optic foramina

**UsesUses::
11--monitoring for vasospasm in patients with subarachnoidmonitoring for vasospasm in patients with subarachnoid
hemorrhagehemorrhage
22--assessing initial collateral blood flow and embolization duringassessing initial collateral blood flow and embolization during
carotid endarterectomy to detect severe ischemia so that a shuntcarotid endarterectomy to detect severe ischemia so that a shunt
can be placed to reduce the risk of strokecan be placed to reduce the risk of stroke
33--assessment of patients suspected of having steno-occlusiveassessment of patients suspected of having steno-occlusive
disease of the intracranial arteriesdisease of the intracranial arteries
44--as a tool to determine risk for transient ischemic attacks (TIA) oras a tool to determine risk for transient ischemic attacks (TIA) or
cardiovascular accidents (CVA) in patients with sickle cell diseasecardiovascular accidents (CVA) in patients with sickle cell disease

55--evaluating the hemodynamic significance ofevaluating the hemodynamic significance of
extracranial vascular atherosclerosisextracranial vascular atherosclerosis
66--detection and assessment of the circulatorydetection and assessment of the circulatory
patterns of arteriovenous malformationspatterns of arteriovenous malformations
77--evaluating cerebral blood flow after traumaevaluating cerebral blood flow after trauma
88--assessing cerebral circulatory arrest as a measureassessing cerebral circulatory arrest as a measure
of brain deathof brain death
99--assessing migraine and tension headacheassessing migraine and tension headache

1010--assessing the adequacy of cerebral blood flowassessing the adequacy of cerebral blood flow
and embolic events during cardiopulmonaryand embolic events during cardiopulmonary
bypass surgerybypass surgery
1111--evaluating blood flow patterns in centralevaluating blood flow patterns in central
nervous system infectionsnervous system infections
1212--evaluating dementiaevaluating dementia
1313--assessing hydrocephalusassessing hydrocephalus
1414--evaluating glaucomaevaluating glaucoma

Radiological anatomy of the Carotid arteries

Radiological anatomy of the Carotid arteries

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Radiological anatomy of the Carotid arteries