Sonographic Sonographic Evaluation of Evaluation of

Neck VasculatureNeck VasculatureCross-Sectional AnatomyCross-Sectional Anatomy

Dr. Harry H. HoldorfDr. Harry H. HoldorfPh.D., MPA, RDMS (Ab, OB, BR) RVT, Ph.D., MPA, RDMS (Ab, OB, BR) RVT,

LRT(AS) LRT(AS)

Table of ContentsTable of Contents AnatomyAnatomy Indications for UltrasoundIndications for Ultrasound The Ultrasound examinationThe Ultrasound examination

2-D2-D Color DopplerColor Doppler Spectral DopplerSpectral Doppler

Diagnostic CriteriaDiagnostic Criteria

Indications for Ultrasound Indications for Ultrasound Evaluation of patients with TIAEvaluation of patients with TIA

Transient Ischemic AttackTransient Ischemic Attack

Evaluation of patients with CVAEvaluation of patients with CVA Cerebrovascular AccidentCerebrovascular Accident

Evaluation of carotid bruitsEvaluation of carotid bruits Follow up of known diseaseFollow up of known disease Monitor endarterectomy resultsMonitor endarterectomy results Evaluation of pulsatile neck massEvaluation of pulsatile neck mass

Carotid Ultrasound Carotid Ultrasound ExaminationExamination

Patient supinePatient supine Neck slightly extendedNeck slightly extended Head slightly turned away from side Head slightly turned away from side

being scannedbeing scanned Linear transducer, 5-12 MHzLinear transducer, 5-12 MHz Protocols vary between operator, Protocols vary between operator,

institutioninstitution B-mode, color Doppler, pulsed Doppler B-mode, color Doppler, pulsed Doppler

Carotid Ultrasound Carotid Ultrasound ExaminationExamination

B-mode images – Transverse/SagittalB-mode images – Transverse/Sagittal Images from proximal CCA to bifurcationImages from proximal CCA to bifurcation Bulb – widening of CCA near bifurcationBulb – widening of CCA near bifurcation Bifurcation – identify and ICA and ECABifurcation – identify and ICA and ECA

Color/DopplerColor/Doppler Proximal/Mid/Distal CCAProximal/Mid/Distal CCA Bifurcation (color)Bifurcation (color) Prox/Mid/Distal ICAProx/Mid/Distal ICA ECAECA VertebralVertebral

More images for pathologyMore images for pathology

AnatomyAnatomy Aortic ArchAortic Arch

Innominate or Brachiocephalic arteryInnominate or Brachiocephalic artery Right subclavian arteryRight subclavian artery Right common carotidRight common carotid

Left common carotid arteryLeft common carotid artery Left subclavian arteryLeft subclavian artery

CCAs lie CCAs lie posterolateral to thyroidposterolateral to thyroid Deep to sternocleidomastoid muscleDeep to sternocleidomastoid muscle

AnatomyAnatomy

AnatomyAnatomy Right CCA originates from innominate Right CCA originates from innominate

arteryartery Left CCA originates from aortic archLeft CCA originates from aortic arch CCAs divide into ECA and ICACCAs divide into ECA and ICA

ICA has no branching vessels in the neck; may ICA has no branching vessels in the neck; may have slight dilation just past its origin; supplies have slight dilation just past its origin; supplies face and head; lies posterior in the neckface and head; lies posterior in the neck

ECA has branching vessels; ECA has branching vessels; usuallyusually smaller smaller than ICAthan ICA

Vertebral Arteries – lie between transverse Vertebral Arteries – lie between transverse process of the vertebraeprocess of the vertebrae

Answers to previous slideAnswers to previous slideAortic arch angiogramAortic arch angiogram1. Innominate art.1. Innominate art.2. Right subclavian art.2. Right subclavian art.3. Right common carotid art.3. Right common carotid art.4. Right vertebral art.4. Right vertebral art.5. Left common carotid art.5. Left common carotid art.6. Left vertebral art.6. Left vertebral art.7. Left subclavian art.7. Left subclavian art.

Muscles and Fascia of Muscles and Fascia of the Neckthe Neck

Deep dissection of neck.Deep dissection of neck.BIF = bifurcation,BIF = bifurcation,

SCM= sternocleidomastoid,SCM= sternocleidomastoid,TM= trapezius muscleTM= trapezius muscle

Common Carotid ArteryCommon Carotid Artery

Carotid BifurcationCarotid Bifurcation

Carotid Bulb with plaqueCarotid Bulb with plaque

Carotid Bulb with StentCarotid Bulb with Stent

CCA: Anterior CCA: Anterior CirculationCirculation

ICAICA The internal carotid artery supplies the brain, the eye, the forehead, and part of the nose. It The internal carotid artery supplies the brain, the eye, the forehead, and part of the nose. It

enters the cranial cavity via the carotid canal in the temporal bone.enters the cranial cavity via the carotid canal in the temporal bone. It gives off no branches within the neck region.It gives off no branches within the neck region. The internal carotid artery supplies perfusion to the anterior and middle portion of the brain, The internal carotid artery supplies perfusion to the anterior and middle portion of the brain,

the eye and its appendages and sends branches off to the forehead and nose. It originates at the eye and its appendages and sends branches off to the forehead and nose. It originates at the carotid bifurcation and courses, via athe carotid bifurcation and courses, via a

number of curvatures, through the base of the skull into the Circle of Willis. number of curvatures, through the base of the skull into the Circle of Willis. The proximal-most portion of this vessel is rather bad bulbous and is referred to asThe proximal-most portion of this vessel is rather bad bulbous and is referred to as the the bulbbulb. Distal to the bulb, the artery narrows and is referred to as the ICA. Distal to the bulb, the artery narrows and is referred to as the ICA proper.proper. Anatomically, the ICA is distinct from the ECA in that there are no branches until it passes Anatomically, the ICA is distinct from the ECA in that there are no branches until it passes

through the base of the skull. through the base of the skull. After coursing anteriorly to the transverse processes of the first three cervical vertebrae (C1 After coursing anteriorly to the transverse processes of the first three cervical vertebrae (C1

–C3), it enters the–C3), it enters the carotid canal carotid canal of the petrous portion of the temporal bone.of the petrous portion of the temporal bone. The intra-petrous portion of the ICA is also referred to as the The intra-petrous portion of the ICA is also referred to as the cavernous portion cavernous portion of the ICA.of the ICA. After coursing through the base of the skull, its first branch arises, the After coursing through the base of the skull, its first branch arises, the ophthalmicophthalmic arteryartery, which supplies blood to the retina. (This is of clinical importance when, which supplies blood to the retina. (This is of clinical importance when discussing amaurosis fugax). discussing amaurosis fugax). At the base of the brain, the ICA gives rise to theAt the base of the brain, the ICA gives rise to the anterior anterior and and middle cerebral arteries. middle cerebral arteries. The site of this branching is often referred to as the The site of this branching is often referred to as the

carotid siphoncarotid siphon..

External Carotid ArteryExternal Carotid Artery

External carotid artery.External carotid artery.Superior thyroidal and lingual artery Superior thyroidal and lingual artery branches are seen in the branches are seen in the submandibular space.submandibular space. The superficial temporal artery lies The superficial temporal artery lies anterior to the ear.anterior to the ear.

Vertebral ArteryVertebral Artery Subclavian StealSubclavian Steal

When a stenosis When a stenosis or occlusion of a or occlusion of a the proximal the proximal subclavian or subclavian or innominate and innominate and the effected side the effected side “steals” blood “steals” blood from retrograde from retrograde vertebral artery vertebral artery flowflow

Vertebral ArteryVertebral Artery

Distinguishing characteristics of Distinguishing characteristics of the vertebral artery:the vertebral artery:First branch off subclavianFirst branch off subclavianEnters foraminal canal at C6Enters foraminal canal at C6Asymmetrical size: left > rightAsymmetrical size: left > rightLow resistance flowLow resistance flow

Carotid Ultrasound Carotid Ultrasound ExaminationExamination

Differentiate ICA/ECADifferentiate ICA/ECA ICA is usually lateral ICA is usually lateral ICA usually larger than ECAICA usually larger than ECA ECA has branchesECA has branches Temporal tap – tapping of superficial Temporal tap – tapping of superficial

temporal artery in the pre-auricular temporal artery in the pre-auricular area; will appear as “saw-teeth” on area; will appear as “saw-teeth” on spectral waveform spectral waveform

Carotid Ultrasound Carotid Ultrasound ExaminationExamination

Gray Scale ImageGray Scale Image Gray-Scale Image Gray-Scale Image

Vessel Wall ThicknessVessel Wall Thickness IM Complex - .8 mm may be considered abnormalIM Complex - .8 mm may be considered abnormal

Plaque CharacterizationPlaque Characterization Homogeneous – smooth surface, uniform echogenicity (p Homogeneous – smooth surface, uniform echogenicity (p

953)953) Calcified – echogenic with posterior shadowing (p 954)Calcified – echogenic with posterior shadowing (p 954) Heterogeneous – complex with at least one sonolucent area Heterogeneous – complex with at least one sonolucent area

corresponding to at least 50% of plaque volume (p 955)corresponding to at least 50% of plaque volume (p 955) Interplaque hemorrhage – “Swiss cheese” appearanceInterplaque hemorrhage – “Swiss cheese” appearance Plaque ulceration – focal depression/break in surface; or Plaque ulceration – focal depression/break in surface; or

anechoic area that extends to plaque surface; use color/power anechoic area that extends to plaque surface; use color/power Doppler (p 952)Doppler (p 952)

Some soft plaque may be very difficult to see on USSome soft plaque may be very difficult to see on US Evaluation of Stenosis – % stenosis by diameter/area Evaluation of Stenosis – % stenosis by diameter/area

– taken in transverse plane (– taken in transverse plane (p 957p 957))

ICA: Duplex characteristics of the ICA. LowICA: Duplex characteristics of the ICA. Lowresistance waveform. Here a clear spectral window isresistance waveform. Here a clear spectral window is

seen under the spectral envelope.seen under the spectral envelope.

Carotid Ultrasound Carotid Ultrasound ExaminationExamination

Color Doppler Color Doppler Color assignment depends on direction of Color assignment depends on direction of

flow relative to the transducerflow relative to the transducer Color saturation indicates variable Color saturation indicates variable

velocitiesvelocities Lower velocities depicted toward baseline, Lower velocities depicted toward baseline,

usually deeper shadesusually deeper shades Higher velocities usually brighter Higher velocities usually brighter

shades/colorsshades/colors Tagging of high velocitiesTagging of high velocities

Gain/Scale settingsGain/Scale settings

Duplex characteristics of the ECA . RapidDuplex characteristics of the ECA . Rapidsystolic upsweep with high resistance flowsystolic upsweep with high resistance flow

pattern during diastole. “Temporal tapping” canpattern during diastole. “Temporal tapping” canbe seen as spectral oscillations during diastole.be seen as spectral oscillations during diastole.

Carotid Ultrasound Carotid Ultrasound ExaminationExamination

Altered flow patternsAltered flow patterns PathologyPathology Normal Normal

At area where vessel branchesAt area where vessel branches Where diameter of vessel changesWhere diameter of vessel changes TortuosityTortuosity

High flow jets after stenosisHigh flow jets after stenosis Low trickle flowLow trickle flow

Carotid Ultrasound Carotid Ultrasound EvaluationEvaluation

Spectral AnalysisSpectral Analysis Graphic display of velocities and Graphic display of velocities and

direction of moving red blood cells in direction of moving red blood cells in the sample volume the sample volume

X axis, Y axisX axis, Y axis Direction of flowDirection of flow Amplitude of “velocity component” (# of Amplitude of “velocity component” (# of

RBCs within each velocity component = RBCs within each velocity component = brightness of the trace)brightness of the trace)

Spectral window – black zone between Spectral window – black zone between baseline and spectral linebaseline and spectral line

CCA Spectral AnalysisCCA Spectral Analysis

Carotid InterpretationCarotid Interpretation Spectral Broadening – occurs when Spectral Broadening – occurs when

blood cells move with a wider range blood cells move with a wider range of velocities; normal spectral of velocities; normal spectral window will be filled inwindow will be filled in Increases in proportion to the severity Increases in proportion to the severity

of stenosisof stenosis Do not confuse with over gain or vessel Do not confuse with over gain or vessel

wall motionwall motion See Rumack p 960 Fig 25-18See Rumack p 960 Fig 25-18

Carotid InterpretationCarotid Interpretation Doppler cursor should be in the Doppler cursor should be in the

center of the vessel, parallel to the center of the vessel, parallel to the vessel walls; on high velocity jetsvessel walls; on high velocity jets

Doppler angles 60 degrees or lessDoppler angles 60 degrees or less Doppler samples obtained just Doppler samples obtained just

proximal to, at and just beyond proximal to, at and just beyond stenosisstenosis

1 cm intervals distal to plaque1 cm intervals distal to plaque

Carotid UltrasoundCarotid Ultrasound ECA – feeds high resistance vascular ECA – feeds high resistance vascular

bed; velocity rises sharply during bed; velocity rises sharply during systole, falls quickly during diastolesystole, falls quickly during diastole

ICA – feeds lower resistance brain ICA – feeds lower resistance brain circulation; large quantities of flow circulation; large quantities of flow continue during diastole; supplies continue during diastole; supplies brain; velocities usually increase brain; velocities usually increase from prox to distalfrom prox to distal

CCA – resembles ICA waveform, with CCA – resembles ICA waveform, with diastolic flow above the baselinediastolic flow above the baseline

Carotid Ultrasound Carotid Ultrasound ExaminationExamination

Diagnostic CriteriaDiagnostic Criteria Carotid artery stenosis (%)– reduction in Carotid artery stenosis (%)– reduction in

diameterdiameter Carotid artery occlusion Carotid artery occlusion

No flow detected with color, pulsed DopplerNo flow detected with color, pulsed Doppler Thrombus/plaque fills vessel lumenThrombus/plaque fills vessel lumen Reversal of flow proximal to occluded segmentReversal of flow proximal to occluded segment

Plaque characterization – as discussed abovePlaque characterization – as discussed above Numerical values of some diagnostic criteria Numerical values of some diagnostic criteria

may very between institutionsmay very between institutions See Rumack p 960See Rumack p 960

Carotid Ultrasound Carotid Ultrasound EvaluationEvaluation

Diagnostic CriteriaDiagnostic Criteria Degree of stenosis assessed using Degree of stenosis assessed using

ICA pre-systolic velocityICA pre-systolic velocity ICA End Diastolic velocityICA End Diastolic velocity PS ICA/CCA ratioPS ICA/CCA ratio PED ICA/CCA ratioPED ICA/CCA ratio No established criteria for grading ECA stenosis No established criteria for grading ECA stenosis

- occlusive plaque in ECA is less common and - occlusive plaque in ECA is less common and rarely clinically significant (Rumack)rarely clinically significant (Rumack)

Velocity criteria used to grade CCA stenosis Velocity criteria used to grade CCA stenosis have not been well established (Rumack)have not been well established (Rumack)

See Rumack p 967See Rumack p 967

Carotid UltrasoundCarotid Ultrasound > 50 % - mild stenosis; not hemodynamically > 50 % - mild stenosis; not hemodynamically

significant significant 50 - 69% moderate stenosis; follow up for 50 - 69% moderate stenosis; follow up for

progression; hemodynamically significant progression; hemodynamically significant 70 – 99% - severe stenosis; operable lesion70 – 99% - severe stenosis; operable lesion Occlusion – concern regarding hemodynamic Occlusion – concern regarding hemodynamic

status of intracranial circulation, not an status of intracranial circulation, not an operable lesionoperable lesion

Ulceration – considered clinically significant; Ulceration – considered clinically significant; can rupture or hemorrhaging; plaque can can rupture or hemorrhaging; plaque can continue to embolize or occlude ICAcontinue to embolize or occlude ICA

Superficial temporal arterySuperficial temporal artery: : Terminal branch of ECA.Terminal branch of ECA.Supplies skin over frontal and temporal regions ofSupplies skin over frontal and temporal regions ofscalp. scalp. The superior temporal artery, which can be The superior temporal artery, which can be

palpated just anterior to the pinna of the ear, is palpated just anterior to the pinna of the ear, is sometimes examined using duplex ultrasound in sometimes examined using duplex ultrasound in patients with suspected temporal arteritis.patients with suspected temporal arteritis.

TEMPORAL TAP METHODTEMPORAL TAP METHOD

The Superior Temporal The Superior Temporal ArteryArtery

Circle of Willis (connecting the Circle of Willis (connecting the two)two)Major collateral pathway of brainMajor collateral pathway of brainBasilar artery formed from fusion of both vertebralsBasilar artery formed from fusion of both vertebralsInternal carotid arteriesInternal carotid arteriesAnterior cerebralAnterior cerebralMiddle cerebralMiddle cerebralBasilar arteryBasilar arteryPosterior cerebralPosterior cerebralCommunicating vesselsCommunicating vesselsAnterior communicating arteryAnterior communicating artery(acoa)(acoa)Posterior communicating arteryPosterior communicating artery(pcoa)(pcoa)

Circle of WillisCircle of Willis

Posterior CirculationPosterior Circulation

ReferencesReferences Araki, C.T. Introduction to Non-Invasive Vascular Testing. Araki, C.T. Introduction to Non-Invasive Vascular Testing.

UMDNJ Vascular Technology Program. UMDNJ Vascular Technology Program. Rumack C., Wilson, S. & Carboneau. Diagnostic Ultrasound, Rumack C., Wilson, S. & Carboneau. Diagnostic Ultrasound,

4thEdition, Vol 1. 2005. 4thEdition, Vol 1. 2005. Image slide 4 retrieved on November 27Image slide 4 retrieved on November 27thth, 2012 from , 2012 from

http://www.vascularultrasound.net/vascular-anatomy/arteries/extracranial

Image slide 6 retrieved on November 27Image slide 6 retrieved on November 27thth 2012 from 2012 from http://www.medison.ru/uzi/eho41.htm http://www.medison.ru/uzi/eho41.htm

Image slide 7 rwetrieved on November 27 2012 from Image slide 7 rwetrieved on November 27 2012 from http://www.specialistvascularclinic.com.au/carotid-interventions.html

Image slide 8 retrieved on November 27Image slide 8 retrieved on November 27thth from from http://www.medicern.co.uk/products/Colour-Portable-Ultrasound/M7-Colour-Doppler-Portable-Ultrasound.html

Image slide 10 retrieved on November 27Image slide 10 retrieved on November 27thth from from http://www.ultrasoundpaedia.com/normal-carotids/

Image slide 24 retrieved on November 28, 2012 from Image slide 24 retrieved on November 28, 2012 from http://www.ajronline.org/content/177/1/53.figures-onlyhttp://www.ajronline.org/content/177/1/53.figures-only