CAROTID DOPPLER STUDY

Dr.I.Gurubharath MD PhD Dr.Pooja MD

 Doppler US Carotid arteries
• Anatomy of Carotid arteries
• Normal Doppler US of carotid arteries
• Causes of Carotid artery disease
• Effect Extra carotid arteries
 CAROTID ARTERY ANATOMY
• The right and left CCAs ascend into the neck
posterolateral to the thyroid gland and lie deep to the
jugular vein and sternocleidomastoid muscle.
• The CCAs have different proximal configurations, with
the right originating at the bifurcation of the innominate
(brachiocephalic) artery into the common carotid and
subclavian arteries.
• The left CCA usually originates directly from the aortic
arch but often arises with the brachiocephalic trunk.
This is known as a “bovine arch” configuration.
• The CCA usually has no branches in its cervical region.
• Occasionally, however, it may give off the superior
thyroid artery, vertebral artery, ascending pharyngeal
artery, and occipital or inferior thyroid artery.
• At the carotid bifurcation, the CCA divides into the
external carotid artery (ECA) and the internal carotid
artery (ICA).
• The ICA usually has no branching vessels in the neck.
• The ECA, which supplies the facial musculature, has
multiple branches in the neck.
• The ICA may demonstrate an ampullary region of mild
dilation just beyond its origin.
Variants resulting due to elongation of ICA
 Patient Position
One is the overhead position, in which the examiner sits beyond the
patient’s head beside the end of the examination table and use two
hands for ultrasonography. Head hyperextended and 45* away from side
being examined. High frequency linear tranducers
 Transducer
• Higher-frequency linear transducers (>7 MHz) are
ideal for assessment of the intima-media
thickness and plaque morphology
• Lower frequency linear transducers (<7 MHz) are
preferred for Doppler examination.
• In a short muscular neck, if imaging with a linear
transducer is impossible, a curved-array
transducer (7 MHz)
All carotids artery examinesd should be performed with:

• Grey scale US
• Color Doppler
• Power Doppler
• Spectral doppler

• Vessels should be imaged as completely as possible

• Caudal angulation of the transducer in the
supraclavicular region and cephalic angulation at the
level of the mandible
 Limitations

 Short muscular neck

 A high carotid bifurcation

 Tortuous vessels

 Calcified shadowing plaques

Avoid excess pressure on carotid bifurcation to avoid

-Stimulate carotid sinus

Bradycardia
Syncope
Ventricular systole

-Compress carotid arteries high velocities

 Optimal Scanning Techniques and Doppler
Settings
• Scan both in transverse and longitudinal plane.
• Starting from proximal most CCA, bulb, ECA and ICA
• Distal carotid ‐2 cm from the bulb
 Color Doppler Sampling Window
•Also known as the color box
•The size is adjusted to include all regions of interest.
•Adjustment of the angle‐by changing the box angles fro
m left to center or right
•Angling the transducer to ensure that the Doppler angl
e is less than 60°to the direction of blood flow
Proper steering
 Sample Volume Gate and Angle Correction

• If the Doppler angle is small or more than 60 degree

small error in the estimated velocity.
• Preferred angle of incidence is 45°±4.
• The optimal position of the sample volume gate in a
normal artery is in the mid lumen parallel to the vessel
wall in a diseased vessel, parallel to the direction of
blood flow

• Should not be placed on the sharp curves of a tortuo-

us artery falsely high velocity reading
• Should not be placed too close to the vessel wall‐spec
tral broadening.
 Spectral Broadening
•Spectral broadening results from turbulence in the bloo
d flow.

Spurious spectral broadening

•A large Doppler angle
•A sample volume gate located close to the vessel wall
•A high Doppler gain setting
•The size of the gate is normally ‐between 2 and 3 mm.
•Too small (1.5 mm) ‐the Doppler signal may be missed
•Too large >3.5 ‐spectral broadening
 Color velocity scale
•If set belowthe mean velocity of blood flow, aliasing
throughout the vessel lumen
•set significantly higher than the mean velocity of b
lood flow, aliasing may disappear resulting in a mi
ssed stenosis
•In a normal carotid US examination, the color velo
city scale should be set between 30 and 40 cm/sec
(mean velocity).
 Color Gain Control
•The color gain should be set so that color just reaches
the intimal surface of the vessel.

•If the color gain setting is too low, trickle flow may go
undetected.
•If a color gain setting is high, “bleeding” of the color
into the wall and surrounding tissues limit visualizatio
n of the plaque surface
 Color Gain Control
•The color gain should be set so that color just reaches
the intimal surface of the vessel.

•If the color gain setting is too low, trickle flow may go
undetected.

•If a color gain setting is high, “bleeding” of the color in

to the wall and surrounding tissues limit visualization o
f the plaque surface
 Role of power doppler

PDI may provide increased sensitivity to visualize the continuity of blood

flow in arterial stenoses
Advantages of power doppler
•Angle independent
•No aliasing
•Very sensitive to low velocity and low amplitude flow
•Helps in differentiating critical stenosis from occlusion

Disadvantages:
Motion sensitive
Does not give direction and velocity of flow
 Technique and
Waveform Analysis
Normal Carotid Artery
 CCA
• Begin proximally in transverse and follow distally to
the bifurcation.
• Assess the course (i.e. if tortuous) and the presence
of any intimal thickening or plaque.
• Repeat in longitudinal plane.
• Use colour to assess patency of vessel and the
direction of flow.
• Use 'Heel/Toe' technique to optimize insonation of
vessel, apply colour box and Doppler sample gate
with appropriate steering and angle correction.
• Measure the Peak Systolic (PSV) and end diastolic
velocities (EDV).
 CCA

• Combination of ICA and ECA patterns,

• Intermediate amount of continuous forward diastolic
flow
• A sharp systolic upstroke and thin spectral envelope
flow below the baseline or filling in of the spectral
window normally should not be seen
 BIFURCATION
• Assess in transverse and longitudinal for pathology.
• Identify the origins of the ICA and ECA arteries.
• Measure the Peak Systolic (PSV) and end diastolic
velocities (EDV) of the ECA.
 ICA

• A low‐resistance waveform pattern

• Systolic peak should be sharp and the spectral en
velope thin continuous forward diastolic flow
• The systolic peak may be slightly blunter than the
systolic peak of the ECA
 ECA

• The systolic upstroke is sharp

• The spectral envelope is thin.
• Reduced to no diastolic flow
• Diastolic flow should be symmetrical bilaterally
transient reversal in early diastole (characteristic ear
ly diastolic notch ) ‐a normal finding
Temporal tap maneuver
Temporal tapping of ECA

“Saw-tooth” appearnce
 Normal flow reversal in ICA

Flow reversal zone

Velocity is highest near the Opposite to the origin of
flow divider ECA
Flow reversal on opposite side
to flow divider
 VERTEBRAL ARTERIES
Return to a longitudinal plane of the CCA and angle the
beam postero-laterally to visualise the vertebral artery.
Ensure suitable PRF and gain for these smaller, deeper
vessels.
The flow should be low resistance flow ( presence of
forward diastolic flow).
Confirm the flow is antegrade i.e. towards the head -
(normal) or retrograde (suggesting subclavian steal
syndrome).
 VERTEBRAL ARTERY

• Low resistance wave pattern

• forward diastolic flow
• no systolic or diastolic notch
• similar to carotid in flow (colour)
• No reversal of wave form
SCA
 Intima –Media complex
Normal <0.8mm
Look At

•Pattern

•Systolic contour

•Diastolic pattern

•PSV

•DV

•ICA PSVs / CCA PSVs ratio

•Compare Right and Left side

 Causes for unilateral low PSVs
• Proximal stenosis (brachiocephalic)
• Parvus tardus waveform or normal pattern but
asymmetrical PSVs.
• Distal stenosis (carotid bulb level)
• High resistance wave form
 Indications for Carotid Ultrasound
• Evaluation of patients with hemispheric neurologic
symptoms, including stroke, transient ischemic attack,
and amaurosis fugax
• Evaluation of patients with a carotid bruit
• Evaluation of pulsatile neck masses
• Evaluation of patients scheduled for major
cardiovascular surgical procedures
• Evaluation of nonhemispheric or unexplained neurologic
symptoms Follow-up of patients with proven carotid
disease Evaluation of patients after carotid
revascularization, including stenting Intraoperative
monitoring of vascular surgery
• Evaluation of suspected subclavian steal syndrome
• Evaluation of a potential source of retinal emboli
• Follow-up of carotid dissection
• Follow-up of radiation therapy to the neck in select
patients
 Causes of carotid artery diseases
Arteriosclerotic disease
NonArteriosclerotic disease
Fibromuscular dysplasia
Dissection
Vasospasm
Aneurysm and pseudoaneurysm
A-V Fistula
Arteritis
Carotid body tumor
 Common sites for extracranial arterial disease

Most common site at carotid bifurcation with plaque extending

into ICA
 Carotid plaque
•Defined as a localized protrusion from the wall into the
lumen with an area 50% greater than the intima media
thickness of neighboring sites.
Parameters and properties of plaques
(a) Plaque extent , Location ,size including the maximally
thick area and the elevated area
(b) Texture, Surface morphology
(c) Internal properties,
(d) Mobility.
(e) Luminal stenosis.
 Texture of Carotid Plaque
Homogeneous (stable)
plaque
Homogeneous
uniform echo pattern
with smooth surface
(acoustic impedance
similar to blood)

Heterogeneous
(unstable) plaque
Mixture of high,
medium, and low-level
echoes with smooth /
irregular surface;
 Ultrasound Types of Plaque Morphology
Type 1: Predominantly echolucent, with a thin
echogenic cap

(A) Sagittal and (B) transverse images show plaque (arrows) virtually
completely sonolucent, consistent with heterogeneous plaque (type 1). Note
smooth plaque surface
Type 2: Substantially echolucent with small areas of echogenicity (>50%
sonolucent)
Type 3: Predominantly echogenic with small areas of echolucency (<50%
sonolucent)
Type 4: Uniformly echogenic
 Plaque types 1 and 2
• Intraplaque hemorrhage and ulceration, Unstable
• Abrupt increases in plaque size after hemorrhage or
embolization.
• Symptomatic patients with stenoses greater than
70% of diameter.

Plaque types 3 and 4

• Fibrous tissue and calcification.
• Homogeneous plaque.
• Benign,
• Stable plaques
• Asymptomatic individuals
 Surface Characteristics of Carotid Plaque
US unreliable due to poor visualization of intima
4 Categories:
• Smooth
• Mildly irregular
• Markedly irregular
• Ulcerated
 Intimal thickening
wavy / irregular line paralleling vessel wall
extending > 1 mm into vessel lumen

Early I-M hyperplasia with loss

of the hypoechoic component of
the I-M complex and thickening
(arrows
 Plaque ulceration
Ultrasound Features Suggestive of Plaque Ulceration

• Focal depression or break in plaque surface

• Anechoic region within plaque extending to vessel
lumen
• Eddies of color within plaque
 Plaque Ulceration and Abnormal Flow. (A) Longitudinal image of the proximal right internal
carotid artery (ICA) demonstrates heterogeneous plaque with an associated area of reversed
low-velocity eddy flow within an ulcer (arrow).
(B) Pulsed Doppler waveforms in this ulcer crater demonstrate the extremely dampened low-
velocity reversed flow, not characteristic of that seen within the main vessel lumen of the
ICA. A
 Gray-Scale Evaluation of Stenosis
Measurements of carotid diameter and area stenosis should be made in the
transverse plane, perpendicular to the long axis of the vessel, using gray-
scale, B-flow, or power Doppler sonographic imaging

(A) Power Doppler transverse image shows a less than 50% diameter
stenosis (cursors). (B) Transverse B-mode flow image of the right carotid
bifurcation shows measurement of stenosis (B) in area of internal carotid
artery (ICA). A, Outer ICA area.
 Circumferential calcified plaque in the proximal ICA.
(a) PW Doppler image of the right ICA obtained immediately distal to a circumferential
shadowing plaque shows no sign of turbulence, and the PSV is within normal limits.
Therefore, there is unlikely to be a significant stenosis behind the calcified plaque.
(b) PW Doppler image of the proximal right ICA shows a tardus-parvus waveform. A
severe proximal stenosis behind the shadowing plaque is suspected; therefore, evaluation
with another imaging modality is required.
 Abnormal CCA
Either low or high psvs.
Abnormally high‐resistance waveform,
An abnormally low‐resistance waveform,
 Abnormally low PSVs

A normal CCA PSV should be in the range of approxi

mately 60 –100 Cm/s
•IF less than this, examine opposite side

Symmetric Asymmetric (near normal)

Low cardiac output

Evaluate further

•A velocity difference of >20 cm/sec between the righ

t and left is abnormal
 Causes for unilateral low PSVs
•Proximal stenosis (brachiocephalic)
Parvus ‐tardus waveform or normal pattern but
asymmetrical PSVs.

•Distal stenosis (carotid bulb level)

High resistance wave form
 Focal stenosis of the CCA
•The ratio of the highest PSV at the CCA stenosis divided
by the PSV 2 cm proximal to the stenosis should be
calculated.
PSV CCA at stenosis/PSV CCA prox.
•If the ratio is 2 or more and less than 2.99 ‐stenosis of
50% or more.
•If the ratio is 3 or more stenosis of 75% or more.
•also used if there are tandem stenosis.
Unusual finding in Case of CCA
occlusion

• Reversal of flow in ECA and low

resistance and low PSVs in ICA as it
is fed by collaterals.
• This is to maintain the antegrade
flow in ICA
 High-velocity flow 627 cm/s,
CCA -mildly elevated resistance
turbulenc
 ICA stenosis
• Most common site is ICA origin plaque extending fro
m the bulb.
• High resistance pattern in the ICA‐Stenosis distally.
• PSVs raises ‐Significant stenosis
Sonographic features of a severe ICA or CCA stenosis
may include the following:
• PSV greater than 230 cm/sec, a significant amount
of visible plaque (50% lumen diameter reduction on a
gray-scale image),
• Color aliasing despite a high color velocity scale
setting (100 cm/sec), Spectral broadening,
• Poststenosis turbulence at color Doppler and
• PW Doppler imaging, color bruit artifact in the
surrounding tissue of the stenotic artery, end-
diastolic velocity of greater than 100 cm/sec,
• ICA/CCA PSV ratio of 4.0 or greater.
• A high-pitched sound at PW Doppler imaging .
Severe stenosis (70% to near occlusion) of the ICA. Duplex US image of the left ICA
shows a high PSV (366 cm/ sec), a significant amount of visible plaque, the
presence of aliasing despite a high color scale setting (114 cm/sec), color flow
turbulence immediately distal to the stenotic segment, broadening of the PW
Doppler spectrum, and a high end-diastolic velocity (182 cm/sec
String sign -Near Total Occlusion
Total Occlusion
 ECA

• Confirm the ECA

• Is there any reversal of flow

• Is there any internalization

VERTEBRAL ARTERY

LOOK AT

Normal or hypoplastic or not seen

Waveform pattern

Direction of flow

PSVs
Reversal of flow–
stenosis or occlusion at subclavian or brachiocephalic ar
tery
•Transient systolic reversal–in lesser digree stenosis

•High resistance wave pattern–distalocclusion or stenosis

•Low resistance wave pattern–more proximal stenosis

Stenosis at vertebral origin-high PSV
SUBCLAVIAN STEAL SYNDROME

•Subclavian artery steno‐occlusive disease proximal to the

origin of the vertebral artery.
•Resulting in decreased blood pressure in the arm distal
to the steno‐occlusive disease.
•Causes ipsilateral vertebral artery blood flow alteration
•Severe stenoses, flow reversal occurs in the ipsilateral
vertebral artery as compensatory collateral to the vascular
territory beyond the subclavian steno‐occlusive lesion.
 Abnormal Vertebral Artery Waveforms
COMPLETE SUBCLAVIAN STEAL
Reversal of flow within vertebral artery ipsilateral to
stenotic or occluded subclavian or innominate artery

INCOMPLETE OR PARTIAL SUBCLAVIAN STEAL

Transient reversal of vertebral artery flow during systole
May be converted into a complete steal using provocative
maneuvers Suggests stenotic, not occlusive, lesion

PRESTEAL PHENOMENON “Bunny” waveform: systolic

deceleration less than diastolic flow May be converted
into partial steal by provocative maneuvers Seen with
proximal subclavian stenosis

TARDUS-PARVUS (DAMPENED) WAVEFORM Seen with

vertebral artery stenosis
Other wave patterns
 PULSUS BISFERIENCE
‘‘Beat twice,’’

•Characterized by two systolic peaks with an interposed

midsystolic retraction
•Seen in AR with or without concomitant AS
Hypertophic obstructive cardiomyopathy
•Occasionally, may be seen in healthy, athletic, young in
dividuals or in older patients.
PULSUS ALTERNANS
•Alternating peak systolic heights on sequential beats in
a regular normal
sinus rhythm
Clinical conditions Intrinsic myocardial disease
• Ischemia
• Cardiomyopathies
• Valvularheart disease
 ‘Water hammer pulse’’
•In aortic reagurgitation –
reversed early diastolic flow in both CCAs with elevation
of PSV and a sharp systolic upstroke
 CAROTID DISSECTION

• Trauma ‐seat belt injury or repetitive trauma.

•Occasionally, spontaneous and isolated to the carotid a
rteries in Marfan syndrome, Ehlers‐Danlos syndrome,
fibromuscular dysplasia, hypertension, or drug abuse
•Also ‐direct extension of an aortic dissection.
•Rare but, dissection of the ICA is the most common ca
use of stroke in young patients.
•Most ICA dissections occur at the level of the carotid b
ifurcation.
 Internal Carotid Artery Dissection:
Spectrum of Findings
INTERNAL CAROTID ARTERY
Absent flow or occlusion
Echogenic intimal flap, with or without thrombus
Hypoechoic thrombus, with or without luminal
narrowing
Normal appearance

COMMON CAROTID ARTERY

High-resistance waveform
Dampened flow
Normal appearance
Abnormal high-resistance waveforms (arrow) at the origin of the right ICA
with no evidence of flow distal to this point (curved arrow).
REFERENCE:
1. Rumack CM, Levine D. Diagnostic Ultrasound E-Book. Elsevier Health
Sciences; 2017 Aug 8.
2. Pozniak MA, Allan PL. Clinical Doppler Ultrasound E-Book: Expert
Consult: Online. Elsevier Health Sciences; 2013 Oct 24.
3. http://www.ultrasoundpaedia.com/