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Carotid Protocol

Scan through each vessel prior to taking any images
This is a bilateral exam. The entire protocol will be performed on the right and left sides.
Structure

Scan Plane

Common
Carotid Artery

Transverse

Bulb
Bifurcation
(ECA and ICA)
Common
Carotid Artery
Proximal
Common
Carotid Artery
Mid
Common
Carotid Artery
Distal

Transverse
Transverse

Label Identify Rt or Lt
and store
measurements
appropriately
CCA PROX
CCA MID
CCA DIST
BULB
BIF

Sagittal

CCA PROX

Sagittal

CCA MID

Sagittal

CCA DISTAL

External Carotid
Artery

Sagittal

ECA

Internal Carotid
Artery

Sagittal

ICA PROX

ICA MID
ICA DISTAL

Common
Carotid Artery
Vertebral Artery

Sagittal

CCA

Sagittal

VERT

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Images Stored

Gray Scale
Gray Scale
Gray Scale
Gray Scale
Gray Scale
Gray Scale
Color Doppler
Color & Spectral Doppler - measure PSV and EDV
Gray Scale
Color Doppler
Color & Spectral Doppler- measure PSV and EDV
Gray Scale - (1-2 cm from bulb)
Gray Scale - (1-2 cm from bulb)
*Zoom in on area with no plaque
Gray Scale - (1-2 cm from bulb)
* Zoom in on area with no plaque
*measure IMT of posterior wall
Color Doppler- (1-2 cm from bulb)
Color & Spectral Doppler - (1-2 cm from bulb) - measure PSV
and EDV
Gray Scale
Color Doppler
Color & Spectral Doppler-Proximal measure PSV and EDV
Gray Scale-Proximal
Color Doppler-Proximal
Color & Spectral Doppler - measure PSV and EDV
Color Doppler
Color & Spectral Doppler - measure PSV and EDV
Color Doppler - (most distal achievable)
Color & Spectral Doppler - (most distal achievable) measure PSV and EDV
Color Doppler
Color Doppler
Color & Spectral Doppler - measure PSV and EDV

Carotid Protocol
Anatomical/Image Correlation
ECA

Dist

Mid

Prox

Prox
Mid

CCA

Dist
ICA

Color Doppler





Will vary with the presence/absence of pathology & curvature of the vessel
Color images should relay the same information as your gray scale & spectral images
Color box should be steered (angled) with the vessel direction
Color in a normal vessel should be free of aliasing and extend to vessel walls
Utilize preset color PRF (scale) and gain, and adjust according to the type of blood flow (velocities) being imaged
 If flow is normal and the color is outside the vessel wall or aliasing in center of vessel, slowly increase PRF
and/or decrease color gain until color is no longer outside the vessel wall or aliasing.
 If flow is normal and the color in the vessel is not filled in, slowly decrease PRF and/or increase color gain
until the color fills the vessel without aliasing or bleeding.
Use power Doppler as needed to document flow in tortuous or deep segments of vessel.
If complete occlusion is suspected, you must document the area with power Doppler to rule out any trickle flow.

Spectral Doppler












Must use angle correct – Angle correct must be less than 60 degrees
Gate (SV length) must be in center of vessel & small width.
Use color Doppler appearance to aid in placement of gate for spectral interrogation. Your goal is to document the
highest velocities present.
Set the PRF (scale) appropriately for the velocities imaged.
Adjust the PRF (scale) to display a large waveform.
Adjust the spectral gain so that there is no background noise on the spectral trace.
Normal ICA waveform is low-resistive, with a brisk systolic acceleration, sharp systolic peak, and a clear spectral
window
Normal ECA waveform is high-resistive, with a brisk systolic acceleration, sharp systolic peak, and a clear spectral
window
Normal CCA waveform is relatively low-resistive (with slightly less diastolic flow than the ICA), with a brisk systolic
acceleration, sharp systolic peak, and a clear spectral window
Elevated velocities with spectral broadening indicate a stenosis
Record velocities in the stenotic area as well as approximately 2 cm prior to (prestenotic) and after (poststenotic)
the area of stenosis
Stenosis is considered hemodynamically significant if the flow in stenotic area is twice the velocity of an area just
previous (prestenotic) to it
Keep in mind that velocities will increase as blood moves through a curved portion of a normal vessel – if no
plaque is seen, Doppler just before or after the curve so that you do not make a make a normal vessel appear
abnormal

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Carotid Protocol
Tips


For the ICA/CCA ratio, use the distal CCA velocity and the highest ICA velocity
Intimal medial thickness (IMT) of the CCA should be measured in the distal CCA (approximately 1-2 cm before the
bulb) along the posterior wall
o Less than 10 mm is considered normal
If retrograde flow is present in either vertebral artery, evaluate the subclavian artery on the affected side and
document with color and spectral Doppler
Ways to differentiate ECA from ICA – It is extremely important that you do not misidentify these vessels!!
o ECA has a branch in the neck (the superior thyroid artery) – the first ICA branch is typically intracranial
o ECA is typically smaller
o ECA waveform is normally high resistive (although an ICA waveform will become high resistive with a
distal stenosis)
o Listen to the waveforms – they should sound different
o Be extra careful with a tortuous ICA that you do not “fall into” the ECA as you move distally
Make sure that you scan as far distally as possible in the ICA

Criteria for ICA Stenosis (adapted from University of Washington and Society of Radiologists in Ultrasound)

Stenosis
0% (normal)
1% - 15%
16% - 49%
50% - 79%
80% - 99%
100% (occluded)

PSV
< 125 cm/s
< 125 cm/s
< 125 cm/s
125 - 200 cm/s
> 200 cm/s
Absent

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ICA/CCA Ratio
< 2.0
< 2.0
< 2.0
2.0 – 4.0
> 4.0
N/A

Spectral Characteristics
No spectral broadening
Spectral broadening in systolic deceleration
Spectral broadening throughout systole
Extensive spectral broadening
Extensive spectral broadening
No flow signal in ICA; minimal diastolic flow or
reversed flow in ipsilateral CCA