Genome-Wide Linkage Analysis of Carotid Ultrasound Phenotypes in Afro-Caribbean Families
CAROTID DUPLEX ULTRASOUND Jenelle (General Ultrasound Department) Anatomy Normal Carotid Ultrasound...
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Transcript of CAROTID DUPLEX ULTRASOUND Jenelle (General Ultrasound Department) Anatomy Normal Carotid Ultrasound...
CAROTID DUPLEX ULTRASOUND
• Jenelle (General Ultrasound Department)• Anatomy• Normal Carotid Ultrasound
• Todd (Vascular Ultrasound Department-Coordinator)• Abnormal Carotid Ultrasound
• Live Scanning• Demonstration by Todd• Practice time – grab a partner!
CAROTID DUPLEX ULTRASOUNDJenelle Beadle
March, 2015
OBJECTIVES
• Anatomy• Classic• Variants
• Carotid Duplex Ultrasound• Indications• Position/Technique• Required Images• Normal spectral analysis
• Tips/Pitfalls
ANATOMY
Cerebrovascular System• supplies the head
Carotid Duplex Ultrasound• exams the extracranial
portion of the cerebrovascular system
Extracranial Cerebrovascular System• Innominate/brachiocephalic• Subclavian• Vertebral• Common Carotid (CCA)• Internal Carotid (ICA)• External Carotid (ECA)
http://www.slideshare.net/shaffar75/doppler-ultrasound-of-carotid-arteries
Innominate/brachiocephalic(Rt sided only)• Originate: Aortic Arch (1st)• Terminate: Rt CCA / Rt
Subclavian
Subclavian Arteries• Originate:
• Rt – Innominate• Lt – Aortic Arch (3rd)
• Branches: Vertebral• Terminate: Axillary
Vertebral Arteries• Originate: Subclavian
Vertebral Arteries• Originate: Subclavian• Pass through transverse
foramena• C6• Atlas (C1)
• Terminate: join to form basilar (intracranial)
Common Carotid Arteries (CCA)• Originate:
• Rt – Innominate• Lt – Aortic Arch (2nd)
• Terminate: ICA/ECA
External Carotid Arteries (ECA)• Originate: CCA
External Carotid Arteries (ECA)• Branches: numerous
• 1st: Superior Thyroid• Terminate: Superficial Temporal / Maxillary
Internal Carotid Arteries (ICA)• Originate: CCA
• NO extracranial branches
Internal Carotid Arteries (ICA)
• Originate: CCA• Branches:
• Intracranial only
Internal Carotid Arteries (ICA)
• Originate: CCA• Branches:
• Intracranial only
• Terminate: • Circle of Willis
Innominate/Brachiocephalic
Innominate/Brachiocephalic
Rt Subclavian
Innominate/Brachiocephalic
Rt Subclavian
Rt Vertebral
Innominate/Brachiocephalic
Rt Subclavian
Rt Vertebral
Rt CCA
Innominate/Brachiocephalic
Rt Subclavian
Rt Vertebral
Rt CCA
Rt ICA
Innominate/Brachiocephalic
Rt Subclavian
Rt Vertebral
Rt CCA
Rt ICA
Lt Vertebral
Innominate/Brachiocephalic
Rt Subclavian
Rt Vertebral
Rt CCA
Rt ICA
Lt Vertebral
Lt ICA
Innominate/Brachiocephalic
Rt Subclavian
Rt Vertebral
Rt CCA
Rt ICA
Lt Vertebral
Lt ICA
Lt ECA
Innominate/Brachiocephalic
Rt Subclavian
Rt Vertebral
Rt CCA
Rt ICA
Lt Vertebral
Lt ICA
Lt ECA
Lt CCA
Innominate/Brachiocephalic
Rt Subclavian
Rt Vertebral
Rt CCA
Rt ICA
Lt Vertebral
Lt ICA
Lt ECA
Lt CCA
Lt Subclavian
Innominate/Brachiocephalic
Rt Subclavian
Rt Vertebral
Rt CCA
Rt ICA
Lt Vertebral
Lt ICA
Lt ECA
Lt CCA
Lt Subclavian
Aortic Arch
ANATOMICAL VARIANTS
Numerous anatomical variants involving the aortic arch branches
VARIANTS• Bovine Arch (10%)• Left vertebral arises
from aortic arch (3%)• Aberrant right
subclavian artery (2%)
CLASSIC (85%)• 3 Branches:
Innominate, Lt CCA, Lt Subclavian
*All other aortic arch variants combined (<1%)
Classic 85% Bovine 10%
Aberrant Rt SCl 2%
Lt Vert 3%
BOVINE ARCH (10%)
Bovine Arch: common origin for Innominate and Left CCA
Normal: 3 separate aortic arch branches
• Most common aortic arch branching variant
BOVINE ARCH (10%)
Bovine Arch: common origin for Innominate and Left CCA
• Most common aortic arch branching variant
Normal: 3 separate aortic arch branches
Bovine Arch: Left CCA originates from Innominate
BOVINE ARCH• Type 2
“BOVINE” ARCH
Misnomer:• Erroneous reference to
cow’s anatomy• Actual cow anatomy
consists of a single trunk branch off the aortic arch
LEFT VERTEBRAL – 3RD BRANCH(3%)• Left vertebral: 3rd branch
• Left subclavian: 4th branch
ABERRANT RIGHT SUBCLAVIAN (2%)• Right subclavian: 4th branch
• Right CCA: 1st branch• No innominate
ICA TORTUOSITY VARIANTS• Course variations are common
http://www.slideshare.net/shaffar75/doppler-ultrasound-of-carotid-arteries
ICA TORTUOSITY VARIANTS• Course variations are common
http://www.slideshare.net/shaffar75/doppler-ultrasound-of-carotid-arteries
ICA/ECA ORIGIN VARIANTS• Variations in origin of the
ECA & ICA are uncommon
• C6 (93%) – most common• C5 (5%) – 2nd most
common
VERTEBRAL ARTERY COURSE VARIANTS
CAROTID DUPLEX ULTRASOUND
INDICATIONS
• Cerebrovascular Accident (CVA)• Transient Ischemic Attacks (TIA)• Cervical Bruit• Pulsatile Mass• Less Specific Symptoms• Dizziness• Headaches
• Pre-operative• Post-operative• Monitor known carotid arterial disease
POSITION/TECHNIQUE
Patient Position
• Supine
• Head angled to the side
• Rolled towel under neck
• Position adjusted to optimize sonographic window
POSITION/TECHNIQUE
Patient Position
• Supine
• Head angled to the side
• Rolled towel under neck
• Position adjusted to optimize sonographic window
Technique
• Highest frequency, penetrating transducer
• Keep angle at 60 degrees• Diagnostic Criteria• Reproducibility
• 3-5 cycles/waveform
• Waveform 2/3 of image• Lower baseline• Decrease scale
EXAM PROTOCOL• Protocol will be available on Sharepoint
• Written and Image formats• Protocol still needs to be approved to be made
official
EXAM PROTOCOL• Protocol will be available on Sharepoint
• Written and Image formats• Protocol still needs to be approved to be made
official• Scan Assistant protocol has been set up in
accordance with written protocol• Protocol will also be set up on Siemens
machine at SH
EXAM PROTOCOL• Protocol will be available on Sharepoint
• Written and Image formats• Protocol still needs to be approved to be made
official• Scan Assistant protocol has been set up in
accordance with written protocol• Protocol will also be set up on Siemens
machine at SH• Examine all accessible portions of the CCA/ICA
• Basic assessment of the ECA/Vert/Subcl
EXAM PROTOCOL• Protocol will be available on Sharepoint
• Written and Image formats• Protocol still needs to be approved to be made
official• Scan Assistant protocol has been set up in
accordance with written protocol• Protocol will also be set up on Siemens
machine at SH• Examine all accessible portions of the CCA/ICA
• Basic assessment of the ECA/Vert/Subcl• Protocol is designed to be the minimal required
images• Additional images will often be necessary when
the exam is normal• Additional images will always be necessary
when pathology is encountered
CCA Proximal• Trans
*Image at the most proximal, straight segment
CCA Proximal• Long
CCA Proximal• Color Doppler
CCA Proximal• Spectral Doppler
CCA Distal• Trans
*2-3cm below the bifurcation
CCA Distal• Long
CCA Distal• Color Doppler
CCA Distal• Spectral Doppler
CCA Spectral Analysis:• EDV should be above zero• EDV should be similar to the contralateral CCA, taken at
approximately the same level
Bifurcation• Trans (bulb)
Bifurcation• Trans (just
above bulb)
ECA Prox• Long
*Look for branches
ECA Prox• Color Doppler
ECA Prox• Spectral Doppler
ECA Spectral Analysis• Higher resistance than the ICA • PSV normally greater ICA• Sharp upstroke• Prominent dicrotic notch (may reverse)• EDV approach/reach zero
*Include bulb
ICA Prox• Long
ICA Prox• Color Doppler
*Obtained just below the bulb where vessel is no longer dilated
ICA Prox• Spectral Doppler
*Waveform may reflect flow disturbances of the bulb extending into the prox ICA
ICA Mid• Color Doppler
ICA Mid• Spectral Doppler
ICA Dist• Color Doppler
ICA Dist• Spectral
Doppler
ICA Spectral Analysis• Low resistance• Continuous forward flow• EDV well above zero
Vertebral• Color Doppler
Vertebral• Spectral
Doppler
Vertebral Spectral Analysis• Low resistance• Slightly more resistive than the ICA
• Antegrade, bidirectional, retrograde
Subclavian• Color Doppler
*Sampled close to the origin
Origin
Subclavian• Spectral Doppler
Subclavian Spectral Analysis• High resistance• Reversal late systole/early diastole
REPEAT ON LEFT
ONLINE FORM
PSV EDV
PSV
TIPS/TRICKS
Long ECA/ICA• Two for the
price of one
Long ECA/ICA• Two for the
price of one
Branches = ECA
Temporal Tap• Tap on superficial temporal artery • ant/sup to ear
• Indicates ECA• Not reliable http://www.slideshare.net/shaffar75/doppler-ultrasound-of-carotid-arteries
http://www.slideshare.net/shaffar75/doppler-ultrasound-of-carotid-arteries
Bulb• “ICA Prox”• Widened portion of the proximal ICA• Disturbed flow• Unidirectional along the flow divider of the birfurcation• Zero/reversed flow at outer wall
Vertebral Origin• Most common
location for stenoses
Innominate• Not required
unless pathology is suspected
CCA
Subclav
Innominate• Not required
unless pathology is suspected
• Distal ICA• can be difficult to
demonstrate
• Prox/Mid ICA Doppler settings are not adequate to optimize the distal ICA• adjustments must be
made
IMAGE QUALITY
Lowered Color Frequency
Increase Color Gain
Decreased Steer Box Angle
BeforeAfter
THE END