CAROTID

DOPPLER
Dr. Rohit Sangolkar
 ANATOMY

All arteries that carry blood from heart up to base of skull

Right & left sides of extra cranial circulation not symmetrical
 VERTEBRAL ARTERY COURSE

BA

V4
V3

V2

V1
V0

VAs asymmetric in 75 % – Left dominant in 80 %

Posteriorly directed loop when exists C1 transverse process
2 VAs units to form basilar artery: collateralization
 VARIATIONS IN EXTRACRANIAL CIRCULATION

 Left CCA & SCA share single trunk

 Left vertebral artery arising directly from aortic arch

 Right vertebral origin arising directly from aortic arch

VARIANTS RESULTING FROM ELONGATION OF ICA
PATIENT POSITION
 Supine with examiner at head end or by the side
 Reclining chair with head rest

 Patient head position away from the side to be

examined, as far away as possible
 POSITION FOR SCANNING THE CAROTID ARTERIES

Patient lie down in supine or semisupine position

Head hyperextended & rotated 45° away from side being examined
Higher-frequency linear transducers (≥ 7.5 MHz)
 All carotid artery examinations should be
performed with:
• Gray-scale US
• Color Doppler
• Power Doppler
• Spectral Doppler
NORMAL CAROTID WALL STRUCTURE
 Intima, media and adventitia represented on B-
mode image
 Intima and adventitia produce parallel echogenic
lines
 Media represented by intervening echo void

 Thickness of intimal reflection exceeds actual

histologic intimal thickness
NORMAL CAROTID WALL STRUCTURE
 Intimal reflection should be straight, thin and
parallel to adventitial layer
 Significant undulation and thickening indicate
plaque deposition/ rarely FMD
 After CEA intimal reflection is missing,
neointima that covers CEA site is not visible
sonographically
 INTIMA-MEDIA COMPLEX
NORMAL VALUE ≤ 0.8 -0.9MM

Wall of CCA, bulb, or ICA

Best measured on far wall
Only intima & media included
 CAROTID BIFURCATION

Longitudinal B-mode image of carotid bifurcation

ICA & ECA seen in same plane
 NORMAL FLOW REVERSAL ZONE IN ICA

Velocities highest near flow divider Flow reversal zone

Flow reversal on opposite side Opposite to origin of ECA
to flow divider
 STANDARD DOPPLER SPECTRAL EXAMINATION

Traces obtained from

• CCA Proximal – Distal

• Carotid Bulb
• ICA Proximal – Middle – Distal
• ECA Proximal
• Vertebral Artery V0 – V1 – V2
• SCA
NORMAL VELOCITY RANGES
 ICA PSV 54-88cm/s ( post bulbar region) ICA
velocity of >100cm/s should be viewed as
potentially abnormal
 ECA PSV mean is 77cm/s. Max PSV does not
exceed 115cm/s
VESSEL IDENTITY
ECA ICA
 Usually smaller  Usually larger
 Branches in neck  No branches
 Anterior/
 Posterior/
anteromedial
posterolateral
 Low resistance
 High resistance
flow Flow
 No deflection with
 Temporal artery
tap - deflection tap
TYPICAL NORMAL DOPPLER SPECTRA
Internal carotid artery

PSV: 45 – 125 cm/sec

Difference between 2 sides < 15 cm/sec

External carotid artery

Triphasic pattern
Dicrotic notch

Common carotid artery

DICROTIC NOTCH
NORMAL FEATURE

Closure of aortic valve with temporary cessation of forward flow

Resumption of forward flow by elastic rebound of aortic wall
COILING OF ICA
CONGENITAL - BILATERAL - SYMMETRICAL
ABNORMAL DOPPLER FLOW IN TORTUOUS VESSEL
Tortuosity can increase velocity, although there is no
stenosis

Tortuous CCA displays color High velocity due to eccentric

Doppler eccentric jets of flow jet in tortuous CCA

DIFFERENTIATION BETWEEN ICA & ECA

Features ICA ECA

 Size Usually larger Usually smaller

 Branches Rarely Yes

 Orientation Posterior Anterior

 Pulsed Low resistance High resistance

Doppler
 Temporal Usually negative Usually positive
tap
 NORMAL CAROTID BIFURCATION
Gray Scale US Color Doppler ultrasound

ICA Larger & lateral

Normal flow separation
ECA Smaller & internal
INTERNAL & EXTERNAL CAROTID ARTERY
Power Doppler US

2 small branches originating from ECA

TEMPORAL TAPPING OF ECA
“SAW-TOOTH” APPEARANCE

Small regular deflections (TT)

Frequency corresponds to rate of temporal tapping
Deflections best seen during diastole
PROTOCOL FOR VA EXAMINATION

Longitudinal VA between transverse processes

– Direction of flow
– Waveform configuration
– Measure PSV

Caudal survey
– Follow artery cauded to its origin

Cephalad survey
– Follow artery cephalad above transverse processes
ULTRASOUND OF NORMAL VERTEBRAL VESSELS
Vertebral artery
Cephalad flow throughout cardiac cycle
Low resistance flow pattern
VA origin regularly seen by experienced sonographers
Size: variable & asymmetric – Mean diameter 4 mm
PSV: 20 – 40 cm/sec – <10 cm/sec potentially abnormal

Vertebral vein
May occasionally be seen adjacent to VA
Flow caudad & nonpulsatile
NORMAL VERTEBRAL ARTERY ORIGIN
V0
NORMAL VERTEBRAL ARTERY & VEIN
V2
Color Doppler Pulsed Doppler

Vertebral artery & vein seen between vertebral processes of spine

SUBCLAVIAN ARTERY
Color Doppler US Pulsed Doppler US

Mirror image below Normal triphasic waveform

pleura
CAUSES OF CAROTID ARTERY DISEASES
Arteriosclerotic disease Most common cause

Non-arteriosclerotic diseases
Fibro muscular dysplasia
Dissection
Vasospasm
Aneurysm & pseudo aneurysm
Arterio-venous fistula
Arteritis: Takayasu – Horton
Carotid body tumor
Idiopathic carotidynia
EXTRACRANIAL CAROTID ARTERY & STROKE
 Stroke is third leading cause of death
 > 500,000 new cases of CVA reported annually

 20 – 30% of stokes due to severe carotid artery

stenosis
 Stenosis involves ICA within 2 cm of bifurcation
 CEA* more beneficial than medical tm in
symptomatic
or asymptomatic patients with > 70% carotid
stenosis**
* CEA: Carotid endarterectomy
** NASCET: North American Symptomatic Carotid Endartectomy Trial
** ECST: European Carotid Surgery Trial
COMMON SITES FOR EXTRACRANIAL ARTERIAL DISEASE

Most common site at carotid bifurcation

with plaque extending into ICA
PLAQUE CHARACTERIZATION
 Echogenicity
Low Lipid –

Moderate Collagen – Easy to see

High with shadow Calcification – Focal or diffuse

 Heterogenous plaque

Calcification: no correlation with neurologic

symptoms
Focal hypoechoic zones: Hemorrhage – Necrosis –
Lipid

 Plaque surface features

Common sources of cerebral emboli: TIA – Stroke

Poor US results for ulcer detection

 PLAQUE TYPES
Type Characteristics Risk
1 Uniformly echolucent High

2 Predominantly echolucent High

(>50%)
3 Predominantly echogenic Lower
(>50%)
4 Uniformly echogenic Lowest
5 Unclassified due to Unknown
calcification or poor
visualisation
Gray-Weale et al Cardiovasc Surg1988, Geroulakos, Ramaswami Br J Surg1993
APPEARANCE OF ATHEROMATOUS PLAQUES
Homogeneous echolucent Homogeneous echogenic

Heterogeneous plaque Cauliflower’ calcification

CALCIFIED PLAQUE

Interrogate artery beyond plaque

Shadowing segment < 1 cm
No turbulent flow: insignificant stenosis
Damped or turbulent flow: tight stenosis

Shadowing segment > 2 cm

Degree of stenosis indeterminate
Other modalities recommended

Calcific plaque with shadow

obscuring portion of the bulb
INTRAPLAQUE HEMORRHAGE
SOURCES OF ERROR IN ULCER DIAGNOSIS
Image plan does not include
the ulcer

Adjacent plaque
simulate ulceration

Plaque surface irregular

but not ulcerated
LARGE PLAQUE ULCER
Color Doppler Power Doppler
Pseudo-dissection “eddy flow”
ULCERATED PLAQUE OR TWINKLE ARTIFACT

Scale 86 cm/sec, color in diastole

Hard plaque in proximal ICA
Color flow disappeared
Questionable flow at plaque surface
Color artifact continues to twinkle
ESTIMATION OF CAROTID STENOSIS

Diameter reduction Surface reduction

RELATIONSHIP BETWEEN DIAMETER REDUCTION
& CROSS-SECTIONAL AREA REDUCTION

Diameter reduction Cross-sectional area

(%) reduction
(%)
30 50

50 75

70 90
CARDINAL DOPPLER PARAMETER TO GRADE STENOSIS
Peak Systolic Velocity (PSV)

Best documented Doppler parameter for carotid stenosis

End Diastolic Velocity (EDV)

Quite valuable for detecting high-grade carotid stenosis

PSV ratio
Avoid errors of collateralization
Avoid errors of physiological factors:
BP – Pulse rate – Cardiac output – Peripheral
resistance
RELATIONSHIP OF FLOW, VELOCITY & LUMEN SIZE

Spencer MP & Reid JM. Stroke 1979 ; 10 : 326 – 330.

GRADING STENOSIS – PSV RATIO

Proximal: 2 cm proximal to carotid bulb

At stenosis: same Doppler angle if possible
Normal value < 2.0
ICA STENOSIS ON ANGIOGRAM

NASCET 1 (1991 – 1998)

North American Symptomatic Carotid Endartectomy Trial
(B – A / B) x 100

ECST 2 (1998)
European Carotid Surgery Trial
(C – A / C) x 100
ICA STENOSIS ON ANGIOGRAM
DIAMETER REDUCTION
* NASCET ** ECST
(B – A / B) x (C – A / C) x 100
100
30% 65%
40% 70%
50% 75%
60% 80%
70% 85%
80% 91%
90% 97%
* NASCET: North American Symptomatic Carotid Endartectomy Trial
** ECST: European Carotid Surgery Trial
DEGREE OF ICA STENOSIS IN DOPPLER US*
CONSENSUS CRITERIA – NASCET CRITERIA
ICA stenosis ICA PSV ICA EDV PSV ratio
(%) cm/sec cm/sec ICA/CCA

Normal < 125 < 40 < 2.0

< 50% < 125 < 40
< 2.0
50 – 69% 125 – 230 40 – 100 2.0 – 4.0
> 70% > 230 > 100 > 4.0
Near occlusion variable variable variable
Total occlusion undetectable undetectable not applicable
DEGREE OF ICA STENOSIS IN DOPPLER US*
CONSENSUS CRITERIA – NASCET CRITERIA

ICA stenosis ICA PSV ICA EDV PSV ratio

(%) cm/sec cm/sec ICA/CCA

Normal < 125 < 40 < 2.0

< 50% < 125 < 40 < 2.0
50 – 69% 125 – 230 40 – 100 2.0 – 4.0
> 70% > 230 > 100 > 4.0
Near occlusion variable variable variable
Total occlusion undetectable undetectable not applicable
ALIASING OR HIGH VELOCITY JET

Area of highest velocity in area of stenosis

ADJUSTMENT OF COLOR GAIN
Color gain at 80% Color gain at 66%

Marked turbulence of ICA & ECA Anatomy of bifurcation

No luminal narrowing demonstrated more accurately
ICA STENOSIS

PSV 500 cm/sec

EDV 300 cm/sec
Spectral broadening
80% diameter stenosis
COLOR DOPPLER BRUIT

Extensive soft tissue color Doppler bruit surrounds

carotid bifurcation with 90% ICA stenosis
Confetti sign
POST STENOTIC ZONE/ IMMEDIATELY AFTER STENOSIS
Spectral broadening
 Cannot be precisely quantified (evaluated visually)
Fill-in of spectral window > 50% diameter
reduction
Severely disturbed flow > 70% diameter
reduction
High amplitude & low frequency Doppler signal
Flow reversal
Poor definition of spectral border
 May be only sign of carotid stenosis in calcified
plaque
SPECTRAL BROADENING
IMMEDIATELY AFTER STENOSIS

High amplitude & low frequency Doppler signal

Poor definition of spectral border
Flow reversal

Severe spectral broadening: > 70% diameter reduction

PSEUDO-SPECTRAL BROADENING
 High gain setting
 Vessel wall motion
 Tortuous vessels
 Site of branching
 Abrupt change in vessel diameter
↑velocity: athlete - high cardiac output - AVF1 -
AVM2
 Aneurysm, dissection, & FMD3
POST STENOTIC ZONE / DISTAL TO SITE OF STENOSIS

Tardus-parvus waveform
SONOGRAPHIC FEATURES OF SEVERE ICA STENOSIS
 Significant visible plaque (≥ 70% diameter
reduction)
 PSV > 230 cm/sec
 EDV > 100 cm/sec
 ICA/CCA PSV ratio ≥ 4.0
 Spectral broadening
 Color aliasing despite high velocity scale (100 cm/sec)
 Color bruit artifact in surrounding tissue of stenosis
 High-pitched sound at pulsed Doppler
TIGHT STENOSIS OR OCCLUSION?

 Difficultto distinguish tight stenosis from

occlusion
 Completely occluded ICA
Will not release emboli
Not corrected by surgery
 Very severe stenosis
Potential source for emboli or acute thrombosis
May require urgent surgery
OPTIMIZATION OF LOW FLOW VELOCITIES

 Decreased color velocity scale

 Increase color, power & pulsed Doppler gain
 Decreased wall filter
 Focal zone at level of diseased segment
 Doppler angle as low as possible (60° or less)
 Increased persistence
 Increase sample volume gate
SUBTOTAL OCCLUSION OF ICA
“STRING SIGN” OR “TRICKLE FLOW ”

Narrow channel of low-velocity in subtotal ICA occlusion

Low PRF & low filter required to detect low-velocity flow

HIGH GRADE “STRING SIGN” STENOSIS

Tardus Parvus waveform

Tardus: Long rise time
Parvus: Low PSV
ENDARTERECTOMY WITHOUT ARTERIOGRAPHY
 Arteriography Expensive
Risks: stroke (0.1 – 0.6%) – death (0.1%)
Rarely affect surgical plan
Sufficient information obtained with
MRI
 Conditions Good experience of US
department
Stenosis localized to carotid bifurcation
Unequivocal US findings
Symptoms ipsilateral to carotid stenosis
CAUSES OF IMAGE/DOPPLER MISMATCH
 Cardiac arrhythmia
 Severe aortic stenosis
 Hypotension or hypertension
 Tortuous vessels
 Hypoechoic, anechoic or calcified plaques
 Long segment high grade stenosis
 Pre-occlusive lesion
 Tandem lesion
 Contra-lateral carotid stenosis
 Carotid dissection
SHORT & LONG STENOSIS OF ICA
Short stenosis (frequent) Long stenosis (rare)

Can produce very high PSV PSV lower than expected

(> 500 cm/s) EDV maintained at high level
LONG STENOSIS OF ICA

RICA: PSV 183 cm/sec

EDV 105 cm/sec
CCA: PSV 76 cm/sec
PSV ratio: 2.4
RICA Inconsistent data

Long stenosis of ICA > 70%

OCCLUSION OF ICA
 Absence of flow by color, power & pulsed Doppler
 “Internalization” of ipsilateral ECA waveform
 Reversed flow in ICA or CCA proximal to occlusion
 Thrombus or plaque completely fills lumen of ICA
 Externalization of ipsilateral CCA or proximal ICA
 Higher velocities in contralateral CCA vs. ipsilateral
CCA
OCCLUSION OF ICA

ICA
CCA

ECA

Retrograde flow in stump of ICA Doppler spectrum from CCA

Absence of flow in ICA beyond Externalization of CCA
OCCLUSION OF ICA
“TO-AND-FRO” FLOW OR THUD FLOW

Pulsed Doppler of CCA

Damped systolic flow

Reversed flow in early diastole
Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.
INTERNALIZATION OF ECA

Patient with complete occlusion of left ICA

OCCLUSION OF CCA

Reversed flow from ECA

to supply ICA & brain
“ECA-to-ICA
collateralization”
OCCLUSION OF CCA

Absence of flow in distal CCA Internalization of ECA

Reversed flow in ECA Delayed systolic acceleration (Tardus)
Normal flow in ICA Positive temporal tap maneuver

Tahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.

STENOSIS OF ECA

Isolated ECA stenosis not clinically significant

 PSV of ECA stenosis Minimal < 200 cm/sec
Moderate 200 – 300
cm/sec
Severe > 300 cm/sec
 ECA/CCA systolic ratio* <2 ≤ 50% Ø stenosis
≥2 ≥ 70% Ø stenosis
ECTATIC CCA

Ectatic CCA as it arises from innominate artery

Responsible for pulsatile right supra clavicular mass
VERTEBRAL ARTERY COURSE

BA

V4
V3

V2

V1
V0

VAs asymmetric in 75 % – Left dominant in 80 %

Posteriorly directed loop when exists C1 transverse process
2 VAs unite to form basilar artery: collateralization
ULTRASOUND OF NORMAL VERTEBRAL VESSELS
Vertebral artery
Cephalad flow throughout cardiac cycle
Low resistance flow pattern
VA origin regularly seen by experienced sonographers
Size: variable & asymmetric – Mean diameter 4 mm
PSV: 20 – 40 cm/sec – <10 cm/sec potentially abnormal

Vertebral vein
May occasionally be seen adjacent to VA
Flow caudad & nonpulsatile
SCHEMATIC DOPPLER WAVEFORMS OF VA
HIGH-RESISTANCE FLOW IN VERTEBRAL ARTERY
Differential diagnosis:

Distal VA stenosis or occlusion

Hypoplastic vertebral artery

Correlation with symptoms

Dizziness
Unsteady walking
High-resistance flow
No diastolic component
ROUTE OF FLOW IN LEFT VERTEBRAL STEAL
SUBCLAVIAN STEAL PHENOMENON REFERS TO
STENO-OCCLUSIVE DISEASE OF THE PROXIMAL
SUBCLAVIAN ARTERY WITH RETROGRADE FLOW
IN IPSILATERAL VERTEBRAL ARTERY
TYPES OF SUBCLAVIAN STEAL
Pre-steal or bunny waveform
Transient reversal of vertebral flow during systole

Converted to partial or complete by provocative

maneuver

Incomplete steal
Striking deceleration of velocity in mid or late
systole
High-grade stenosis of subclavian rather than
occlusion

Complete steal
Complete reversal of flow within vertebral artery
VERTEBRAL TO SUBCLAVIAN STEAL
Compared to bunny in profile

Presteal

Incomplete steal

Complete steal
PROVOCATIVE MANEUVER IN STEAL SYNDROME
Inflation of pressure cuff on arm for 3 min & rapid
deflation
By exercising the diseased limb also cause
provocation
Pre-steal More pronounced steal

Conversion of pre-steal waveform to more pronounced

steal
following deflation of pressure cuff
CAUSES OF CAROTID ARTERY DISEASES
Arteriosclerotic disease
Non-arteriosclerotic diseases
Fibromuscular dysplasia
Dissection
Vasospasm
Aneurysm & pseudoaneurysm
Arterio-venous fistula
Arteritis: Takayasu – Horton
Carotid body tumor
Idiopathic carotidynia
FIBROMUSCULAR DYSPLASIA
MIDDLE AGE WOMEN – RENAL ARTERIES – STRING OF BEADS
PATTERN

ICA

Alternating zones of vasoconstriction & vasodilatation for 3 – 5 cm

ICA frequently – VA less frequently
Usually bilateral
CAROTID & VERTEBRAL DISSECTION

 Spontaneous dissection Bleeding from vasa vasorum

Most common ICA & VA (atlas loop)
Intramural hematoma
Pain – Stenosis – Horner
 Vascular injury Iatrogenic: puncture – surgery
CCA
Intramural hematoma ± intimal
tear
 Stanford A dissection Intimal rupture in ascending aorta
CCA
DISSECTION OF AORTA & CERVICAL ARTERIES
PATHO-ANATOMY
Aorta Cervical

Intimal rupture with false lumen External intramural hematoma

Open or secondarily thrombosed Lumen constriction
Rare intimal rupture
SPONTANEOUS DISSECTION OF ICA
Asymmetric wall hematoma – Lumen stenosis – Expansion to outside
Diagnostic criteria (one sufficient)

Intramural hematoma

Intimal rupture/double lumen

Distal stenosis or occlusion

Symptoms: acute pain, Horner,

Course: recanalization in few weeks

a Longitudinal color Doppler ultrasound (US) image of an acute dissection of the

internal carotid artery (ICA) with the dissection of the lumen (arrowhead)
demonstrating color flow. ICA large arrow, external carotid artery (ECA) long
arrow. b An abnormal high-resistance spectral Doppler US waveform is
demonstrated in the dissection lumen (arrowhead). ICA large arrow, ECA long
arrow. c. On day 14, there is intramural thrombus formation (arrowhead) with
no evidence of color Doppler US flow within the dissection false lumen. CCA star,
ICA large arrow, ECA long arrow
SPONTANEOUS DISSECTION OF VA
Wall hematoma in V1 Double lumen in V2

Diagnostic criteria (one sufficient):

Intramural hematoma (asymmetric, not concentric)
Intimal rupture/double lumen (rare)
DISSECTION OF COMMON CAROTID ARTERY
Detection of two lumina & dissection membrane
Transverse view Longitudinal view
DISSECTION OF CCA / STENOSIS
RESIDUUM AFTER END OF AORTIC DISSECTION
Doppler of true lumen Doppler of false lumen

Enlargement of false lumen

Stenosis of true lumen
before cranial end
VASOSPASM
 Causes Migraine, eclampsia, vasculitis, drug abuse,
idiopathic
 Incidence Rarely identified (short duration)
Occur frequently & remain undetected
 Symptoms Cerebral or ocular ischemia
 US Direct &/or indirect signs of severe stenosis
Far above bifurcation – Sometimes bilateral
Complete regression in hours to days – Relapse
 DD Dissection: wall hematoma – regression in weeks
 Treatment Calcium antagonists
VASOSPASM
Severe narrowing of ICA No stenosis detected

4 days later
EXTRA-CRANIAL ICA ANEURYSMS
Color Doppler US Power Doppler US

Incomplete delineation of aneurysm – Thrombi could not be excluded

Difficult definition for extracranial carotid artery aneurysms

due to normal dilatation of bulb
ICA ANEURYSM / PARIETAL THROMBOSIS
Longitudinal section Transversal section

Aneurysm of proximal ICA

Parietal thrombus & homogeneous thickening of vessel
wall
CCA ANEURYSM / RUPTURE
CCA PSEUDOANEURYSM / RARE
ONE MONTH AFTER BILATERAL NECK DISSECTION
Color Doppler US CE multidetector CT

CCA Pseudoaneurysm CCA Pseudoaneurysm

Large connecting neck Large connecting neck
ARTERIO-VENOUS FISTULA
ATTEMPT TO PERFORM US-GUIDED JUGULAR CATHETER
INSERTION

IJV
CCA

Suspicion of communication between CCA & IJV

Turbulent flow in fistula track High-velocity turbulent flow in track

DOPPLER ULTRASOUND IN ARTERITIS
“MACARONI SIGN” & “HALO SIGN”
 2 types Takayasu Young female – SCA & CCA
Horton Old female – SCA, AA & Temporal
A
Cannot be differentiated using US
 US signs Macaroni Concentric hypoechoic wall
thickening
Halo Dark halo around colorful lumen
All grades of stenosis – Thrombotic vessel
 DD Dissection Eccentric hypoechoic wall
thickening
Pronounced outward expansion
TAKAYASU’S ARTERITIS
YOUNG FEMALE – SCA [‘PULSELESS’ DISEASE] – CCA
CCA

Long hypoechoic wall thickening

Visualized in color Doppler as dark halo around vascular lumen
HORTON'S ARTERITIS / GIANT CELL ARTERITIS
CONCENTRIC HYPOECHOIC WALL THICKENING
Superficial temporal artery

VA – Longitudinal view VA – Transverse view

CAROTID BODY TUMOR / RARE
Histology Paraganglioma of low malignant potential
Presentation Palpable neck mass – Headache – Neck pain
US Highly vascular mass in carotid bifurcation
Arteriography Performed preoperatively – Embolization
Treatment Resection to prevent local adverse events:
Laryngeal nerve palsy – carcinoma invasion
Result Local recurrence 6% – Distant metastasis 2%
CAROTID BODY TUMOR
HIGHLY VASCULAR MASS IN CAROTID BIFURCATION
DIAGNOSIS OF IDIOPATHIC CAROTIDYNIA
INTERNATIONAL HEADACHE SOCIETY (IHS)1

 At least one of following over CA: Tenderness

Swelling
Increased pulsations
 Pain over affected side of neck that may project to head
 Appropriate investigations without structural abnormality
Recent publications demonstrate radiological
findings2
 Self-limiting syndrome of less than 2 weeks duration
IDIOPATHIC CAROTIDYNIA
US FINDINGS COMPARABLE TO DISSECTION
US of distal CCA CE T1-weighted MRI Three months later

Hypo-echoic soft tissue Enhanced tissue Resolution of abnormal

around carotid artery around carotid artery soft tissue
SPONTANEOUS DISSECTION & CAROTIDYNIA
Spontaneous dissection Carotidynia

Location Beyond bifurcation At or near

bifurcation

Thickening layers One wall layer 2 wall layers

Stenosis May be detectable Not detectable

Pain Head Neck

In unclear cases, MRI enables differentiation

EFFECT OF EXTRA-CAROTID DISEASES

 Idiopathic dilated cardiomyopathy

 Aortic regurgitation
 Aortic stenosis
 Stenosis of right innominate artery or origin of
LCCA
 High & low PSV in CCA
 Stenosis of intra-cranial ICA
IDIOPATHIC DILATED CARDIOMYOPATHY
PULSUS ALTERNANS

PSV oscillating between two levels on sequential beats

Cardiac rhythm remains regular throughout
AORTIC REGURGITATION
BISFERIENS WAVEFORM [“BEAT TWICE” IN LATIN]

Two systolic peaks separated by midsystolic retraction

Dicrotic notch
Found also with hypertrophic obstructive cardiomyopathy
SEVERE AORTIC REGURGITATION
Water-hammer spectral appearance
CCA
AORTICRCCA
STENOSIS
– Tardus Parvus LCCA – Tardus Parvus

RVA – Tardus Parvus

RIGHT INNOMINATE ARTERY STENOSIS
RCCA – Tardus-Parvus LCCA – Normal waveform

RVA – Reversed flow

RIGHT INNOMINATE ARTERY STENOSIS
Right carotid steal
RICA : to-and-fro flow

RCCA : to-and-fro flow

RVA : reversed flow

RSCA : damped flow

 Normal PSV in CCA (45 – 125 cm/sec)

High flow > 125 cm/sec in both CCAs

High cardiac output: Hypertensive
patients
Younginathletes
Low flow < 45 cm/sec both CCAs

Poor cardiac output: Cardiomyopathies

Valvular heart disease
Extensive myocardial
infarction Arrhythmias can be real problem
STENOSIS OF INTRA-CRANIAL ICA
HIGH RESISTANCE WAVEFORM

ICA

High-grade stenosis distally (intracranial ICA)

Major occlusive lesions of cerebral arteries (MCA, ACA)
Massive spasm of cerebral arteries from intracranial hemorrhage
ADVANTAGES OF POWER MODE DOPPLER
 Angle independent
 No aliasing
 Increases accuracy of grading stenosis
 Distinguish pre-occlusive from occlusive
lesions
“detect low-velocity blood flow”
 Superiordepiction of plaque surface
morphology
DISADVANTAGES OF POWER MODE DOPPLER

 Does not provide direction of flow

New machines provide direction of flow in power
mode

 Does not provide velocity flow information

 Very motion sensitive (poor temporal resolution)

LIMITATIONS OF CAROTID US EXAMINATION
 Short muscular neck
 High carotid bifurcation
 Tortuous vessels
 Calcified shadowing plaques
 Surgical sutures, postoperative hematoma, central
line
 Inability to lie flat in respiratory or cardiac disease
 Inability to rotate head in patients with arthritis
 Uncooperative patient
THANK YOU