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 Label - Images Stored
Plane Identify Rt or
Lt and store
measurement
s
appropriately
Common Transvers CCA PROX Gray Scale
Carotid e CCA MID Gray Scale
Artery CCA DIST Gray Scale
Bulb Transvers BULB Gray Scale
e
Bifurcation Transvers BIF Gray Scale
(ECA and e
ICA)
Common Sagittal CCA PROX Gray Scale
Carotid Color Doppler
Artery Color & Spectral Doppler - measure PSV and
Proximal EDV
Common Sagittal CCA MID Gray Scale
Carotid Color Doppler
Artery Color & Spectral Doppler- measure PSV and EDV
Mid
Common Sagittal CCA DISTAL Gray Scale - (1-2 cm from bulb)
Carotid Gray Scale - (1-2 cm from bulb)
Artery *Zoom in on area with no plaque
Distal 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
External Sagittal ECA Gray Scale
Carotid Color Doppler
Artery Color & Spectral Doppler-Proximal measure PSV
and EDV
Internal Sagittal ICA PROX Gray Scale-Proximal
Carotid Color Doppler-Proximal
Artery Color & Spectral Doppler - measure PSV and
EDV
ICA MID Color Doppler
Color & Spectral Doppler - measure PSV and
EDV
ICA DISTAL Color Doppler - (most distal achievable)
Color & Spectral Doppler - (most distal
achievable) - measure PSV and EDV
Common Sagittal CCA Color Doppler
Carotid
Artery
Vertebral Sagittal VERT Color Doppler

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Carotid Protocol
Artery Color & Spectral Doppler - measure PSV and
EDV

Anatomical/Image Correlation
ECA

Dist Mid Prox
Prox
Mid CCA
Dis
t 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.

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Carotid Protocol
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

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 PSV ICA/CCA Ratio Spectral Characteristics
0% (normal) < 125 cm/s < 2.0 No spectral broadening
1% - 15% < 125 cm/s < 2.0 Spectral broadening in systolic
deceleration

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Carotid Protocol
16% - 49% < 125 cm/s < 2.0 Spectral broadening throughout
systole
50% - 79% 125 - 200 2.0 – 4.0 Extensive spectral broadening
cm/s
80% - 99% > 200 cm/s > 4.0 Extensive spectral broadening
100% Absent N/A No flow signal in ICA; minimal diastolic
(occluded) flow or reversed flow in ipsilateral CCA

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