CAROTID AND VERTEBRAL ULTRASONOGRAPHY

Daniel Makes Department Of Radiology Faculty Of Medicine University of Indonesia / Cipto Mangunkusumo Hospital Jakarta Indonesia

Ultrasound is non-invasive and more readily available than other techniques-digital subtraction angiography (DSA), computed tomography angiography (CTA) & MRA and, uniquely, it can visualise the arterial wall itself

Stroke is a significant public health problem, with an incidence of 2,9 per 1000 population in England and Wales with a recurrence rate of between 20 % and 50 % within 5 years

Thromboembolic disease is a major cause of stroke secondary to atherosclerosis, which is the formation of fibrofatty plaques within the intima of the arteries and arterioles

Atherosclerotic lesions may develop inflammatory changes, cholesterol crystals, necrotic debris, and subintimal haemorrhage If the plaque ruptures, it may release these materials as emboli and / or cause thrombus formation on the ulcerated surface, thus placing the patient at risk of cerebral thromboembolic disease

50-60 % of patients with transient ischaemic attacks (TIAs) have less than a 50 % stenosis on cerebral arteriography TIAs are followed by stroke within 5 years in 33 % of patients, the period of greatest risk being the first two weeks after a TIA

The North American Symptomatic Carotid Endarterectomy Trial (NASSCET), European Carotid Surgery Trial (ECST) and Asymptomatic Carotid Atherosclerosis Study (ACAS) have clearly demonstrated the benefit of carotid endarterectomy for symptomatic patient with > 70 % diameter stenosis

Prime indication of ultrasound is to identify flow-limiting stenoses, especially high grade stenoses (> 70 %), in symptomatic patients who are likely to benefit from carotid endarterectomy

EQUIPMENT
A high resolution linear transducer Duplex or triplex display mode option (real-time grey-scale image + spectral Dopller analysis + colour flow imaging) Adjustable wall filter, ultrasound beam angle steering, angle correction

SCANNING PROTOCOL
1. Patient position Supine Neck slightly extended Head turned away from the side being examined 2. Regions of interest Both CCAs from the origins to the bifurcations Both ICAs and ECAs as cephalad as possible Both vertebral arteries (the proximal and the interforamina segments)

Procedure
Examine the carotid arteries transversely, followed by longitudinal scans Record any plaque formation, its location, extent and morphology Quantify the degree of stenosis

Examine the vertebral arteries by duplex sonography

Handling the transducer in duplex sonography of the neck arteries

Sectional planes used in examining the carotid system in the neck with duplex sonography

Anatomy of the large arteries supplying the brain

Normal CCA and Bifurcation

Normal Carotid Bifurcation

Normal Carotid Bulb

The normal dimensions of the carotid arteries are :

1. CCA : 6.3 + 0,9 mm 2. ICA : 4.8 + 0,7 mm 3. ECA : 4.1 + 0,6 mm

DIFFERENTATION OF THE EXTRACRANIAL ICA AND ECA

1. 2. 3. There is no branch of the extracranial ICA The first branch of the ECA superior thyroid artery is readily detectable on ultrasound In 90 % of cases, the ICA runs lateral or posterolateral to the ECA The ICA has a larger calibre than the ECA The Doppler waveform of the ICA is of low resistance with a high diastolic component while that of the ECA is of high resistance with a low or zero diastolic component There is prominent disturbance in the ECA Doppler waveform during the tapping manoeuvre of the superficial temporal artery

4. 5.

6.

Normal Brachiocephalic Bifurcation

Normal Common Carotid Artery

Normal Internal Carotid Artery

Normal External Carotid Artery

Fig.11.4

PLAQUE CHARACTERISATION
Prediction of subsequent stroke by plaque morphology is controversial
Detection of ulcers in a plaque correlates better with the risk of recurrent cerebral embolism

Sensitivity for plaque ulceration is poor with transcutaneous ultrasound

CAROTID ARTERIES Intima-media thickness (IMT)

The IMT is defined as the distance between the leading edges of the lumen-intima interface and the media-adventina interface of the outer wall

Measurements should be made on a magnified view to minimise error

The IMT ranges from 0.5 mm to 1.0 mm in healthy adults at all ages, values over 1.0 mm are regarded as abnormal

Detectable atherosclerotic lesions are defined as IMT > 1.2 mm whereas moderate to severe thickening is present when IMT is greater than 2 mm

Soft Plaque

Dense Plaque

Calcified Plaque

Ulcerated Plaque with Hemorrhage

Calcified plaque with acoustic shadowing

Fibromuscular Hyperplasia

a. Mild stenosis b. Moderate stenosis c. Severe stenosis d. Subtotal stenosis

Doppler spectral analysis of various diagnostic parameters

Moderate stenosis
a. Color doppler image shows a color mosaic pattern representing the stenosis

b. Spectral analysis shows minimal spectral broadening and moderately elevated frequencies

Spectral Broadening
a. Minimal spectral broadening with moderate stenosis b. Complete filling of the spectral window with critical stenosis

Distal carotid siphon stenosis with abnormal proximal waveform

Internal carotid artery dissection

Tortousity
a. The S-shaped tortuous internal carotid artery b. Long tortuous internal carotid artery c. Tortuosity seen with power doppler

Brachiocephalic artery aneurysm

a. Color Doppler image shows the aneurysm b. Angiography demonstrates the aneurysm

Vertebral Artery

Normal Vertebral Artery

Atherosclerotic lesions of the vertebral arteries commonly occur at the origin of the vertebral artery

Normal Vertebral Artery

Normal Vertebral Artery

Vertebral artery calcification

Vertebral artery stenosis

Critical subclavian artery stenosis

Subclavian Steal
a. Stenosis b. Occlusion

CONCLUSION

You should always increased your skill to increase your diagnostic accuracy