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.
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
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
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
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
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%
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
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
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
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.