Basic Objectives of Color and spectral Doppler

To assess normal Carotid artery anatomy.

Assessing the direction of flow
Assessing the character of flow
Localizing stenotic lesions for spectral sample placement
Assess degree of occlusion
Indications of Carotid Doppler Ultrasound:
Family history of stroke or heart disease.
Recent transient ischemic attack (TIA) or stroke.
Abnormal sound in carotid arteries (bruit).
Coronary artery disease.
Approach:
1. Approach the patient from the lateral sitting position
(RT side)
This position makes it easy to control the machines. (More popular with
Radiologists)
2. Approach the patient from overhead position. This requires the operator to scan
with both hands. (Popular with vascular surgeons)

Patient position:
A pillow is not necessary, as it produces a poor window for the carotid artery. The neck
of the patient should be relaxed. The head should be tilted 45 degrees away from the
artery being examined.

Transducer Position:
Long Axis (Longitudinal) planes require that the transducer is placed at far
posterolateral aspect of the sternocleidomastoid muscle, to view CCA, ICA and ECA.
Short axis (Transverse) views are obtained by anterior, lateral or posterolateral
approach.
Normal flow characteristics:
1. The normal flow is Laminar flow (Parabolic flow).
2. The abnormal flow is Turbulent flow which is
random and chaotic.
This often occurs just beyond the obstruction.

Tips before you begin:

Avoid excess pressure on carotid bifurcation to
avoid Carotid Sinus stimulation resulting Bradycardia, Syncope, Ventricular
asystole.
Avoid compressing the arteries too hard to avoid spurious high velocities.
Harmonic imaging recommended to improve resolution & reduce artifacts.
Power Doppler imaging is recommended to assess low flow states and possible
occlusions.
Doppler angle should be 60 degrees or less.
Sample volume should be ½ or 1/3rd of the vessel lumen and placed in the in the centre
of the vessel.
Traces are obtained from:
1. CCA Proximal and Distal
2. Carotid bulb
3. Bifurcation
4. ICA Proximal, Mid and Distal
5. ECA Proximal
6. Vertebral Artery
7. Subclavian Artery

CCA: It is the main artery supplying the brain. It is seen in neck at the level of Thyroid
gland, originating from the Subclavian artery and ends at the CC bulb. It has a mixed
flow.
ECA: does not supply blood to brain. It has usually several branches and has a high
resistance flow. It becomes an important collateral pathway if occlusion occurs in ICA
or VERTIBERAL ARTERIES.
ICA: is usually without any branches. It supply’s the brain and has a low resistance
flow.
Vertebral Artery: Arises from the subclavian artery, runs through the spinous
processes of cervical spine and supplies the brain. It direction (Normally towards the
brain) is very important in diagnosing the subclavian steel.

Normal Vertebral artery flow Vertebral artery flow reversal in Subclavian steel

Normal Spectral waveform Occluded ICA

ECA and ICA differences:

Features ECA ICA

Size Usually small Usually large

Branches Always Very rare

Orientation Antero-Medial Postro-Lateral

Doppler High Resistance Low Resistance

Response to Temporal Well Perceived Poor to absent

tap oscillations

Temporal tap: This is an extremely helpful manoeuvre to differentiate between ICA

and ECA partial or complete occlusion.

References: General principles of Carotid Doppler Ultrasonography

Peripheral Vascular Ultrasound How, Why and When, 2nd Edition.
Introduction to Vascular Ultrasonography, 6th edition
Netter Atlas of Human Anatomy, 7th edition.