carotid and vertebral ultrasonography- dr. daniel
TRANSCRIPT
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CAROTID AND VERTEBRAL
ULTRASONOGRAPHY
Daniel Makes
Department Of Radiology
Faculty Of Medicine University of Indonesia /
Cipto Mangunkusumo Hospital
Jakarta Indonesia
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Ultrasound is non-invasive andmore readily available thanother techniques-digitalsubtraction angiography
(DSA), computed tomographyangiography (CTA) & MRA and,uniquely, it can visualisethe arterial wall itself
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Stroke is a significantpublic health problem,with an incidence of 2,9per 1000 population inngland and Wales witha recurrence rate of
between 20 and 50within 5 years
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Thromboembolic disease isa major cause of strokesecondary toatherosclerosis, which isthe formation of fibrofattyplaques within the intima
of the arteries andarterioles
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Atherosclerotic lesions may develop
inflammatory changes, cholesterol
crystals, necrotic debris, andsubintimal haemorrhage
If the plaque ruptures, it may releasethese materials as emboli and / or
cause thrombus formation on the
ulcerated surface, thus placing thepatient at risk of cerebral
thromboembolic disease
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50-60 % of patients withtransient ischaemic attacks
(TIAs) have less than a 50 %stenosis on cerebral
arteriography
TIAs are followed by strokewithin 5 years in 33 % of
patients, the period of greatestrisk being the first two weeksafter a TIA
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The North American SymptomaticCarotid Endarterectomy Trial(NASSCET), European CarotidSurgery Trial (ECST) andAsymptomatic CarotidAtherosclerosis Study (ACAS) haveclearly demonstrated the benefit ofcarotid endarterectomy for
symptomatic patient with > 70diameter stenosis
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Prime indication ofultrasound is to identifyflow-limiting stenoses,especially high gradestenoses (> 70 ), insymptomatic patients whoare likely to benefit fromcarotid endarterectomy
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EQUIPMENT A high resolution linear transducer Duplex or triplex display mode
option (real-time grey-scale image +spectral Dopller analysis + colourflow imaging) Adjustable wall filter, ultrasound
beam angle steering, anglecorrection
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SCANNING PROTOCOL1. Patient position
Supine Neck slightly extended Head turned away from the sidebeing examined
2. Regions of interest Both CCAs from the origins to thebifurcations Both ICAs and ECAs as cephalad as
possible Both vertebral arteries(the proximal and the interforaminasegments)
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Procedure Examine the carotid arteriestransversely, followed bylongitudinal scans Record any plaque formation, itslocation, extent and morphology Quantify the degree of stenosis Examine the vertebral arteries byduplex sonography
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Handling the transducer in duplexsonography of the neck arteries
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Sectional planes used in examiningthe carotid system in the neck withduplex sonography
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Anatomy of the large arteriessupplying the brain
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Normal CCA and Bifurcation
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Normal Carotid Bifurcation
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Normal Carotid Bulb
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The normal dimensions ofthe carotid arteries are :
1. CCA : 6.3 + 0,9 mm2. ICA : 4.8 + 0,7 mm
3. ECA : 4.1 + 0,6 mm
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Normal Brachiocephalic Bifurcation
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Normal Common Carotid Artery
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Normal Internal Carotid Artery
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Normal External Carotid Artery
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Fig.11.4
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PLAQUECHARACTERISATIONPrediction of subsequent stroke byplaque morphology is controversial
Detection of ulcers in a plaquecorrelates better with the risk ofrecurrent cerebral embolismSensitivity for plaque ulceration is poorwith transcutaneous ultrasound
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CAROTID ARTERIESIntima-media thickness(IMT)
The IMT is defined as the distancebetween the leading edges ofthe lumen-intima interface and
the media-adventina interface ofthe outer wallMeasurements should be made on
a magnified view to minimise error
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The IMT ranges from0.5 mm to 1.0 mm
in healthy adults at allages, values over1.0 mm are regarded asabnormal
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Detectable atheroscleroticlesions are defined asIMT > 1.2 mm whereasmoderate to severethickening is present whenIMT is greater than 2 mm
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Soft Plaque
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Dense Plaque
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Calcified Plaque
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Ulcerated Plaque with Hemorrhage
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Calcified plaque with acousticshadowing
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Fibromuscular Hyperplasia
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a. Mild stenosisb. Moderatestenosisc. Severestenosisd. Subtotalstenosis
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Doppler spectral analysis of variousdiagnostic parameters
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Moderate stenosisa. Color doppler imageshows a color mosaicpattern representingthe stenosisb. Spectral analysisshows minimalspectral broadeningand moderatelyelevated frequencies
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Spectral Broadeninga. Minimal spectral broadening with
moderate stenosisb. Complete filling of the spectral windowwith critical stenosis
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Distal carotid siphon stenosis withabnormal proximal waveform
I t l tid t di ti
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Internal carotid artery dissection
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Tortousitya. The S-shaped
tortuous
internal carotid
arteryb. Long tortuous
internal carotid
artery
c. Tortuosity seenwith power
doppler
Brachiocephalic artery
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Brachiocephalic artery
aneurysm
a. Color Doppler image shows the aneurysmb. Angiography demonstrates the aneurysm
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Vertebral Artery
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Normal Vertebral Artery
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Atherosclerotic lesionsof the vertebral arteriescommonly occurat the origin of
the vertebral artery
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Normal Vertebral Artery
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Normal Vertebral Artery
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Vertebral artery calcification
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Vertebral artery stenosis
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Critical subclavian arterystenosis
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Subclavian Steala. Stenosisb. Occlusion
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CONCLUSION
You should always
increased your skillto increase your
diagnostic accuracy