Carotid ultrasonography

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Carotid ultrasonography
Left proximal internal carotid artery normal spectral doppler.jpg
Screenshot of a normal proximal internal carotid artery spectral Doppler
PurposeImaging used to evaluate structural details and blood flow of the carotid arteries

Carotid ultrasonography is an ultrasound-based diagnostic imaging technique to evaluate structural details of the carotid arteries. Carotid ultrasound is used to diagnose carotid artery stenosis (CAS) and can assess atherosclerotic plaque morphology and characteristics. [1] Carotid duplex and contrast-enhanced ultrasound are two of the most common imaging techniques used to evaluate carotid artery disease.

Contents

Medical Uses

Carotid ultrasound is a low-cost, noninvasive, and accurate diagnostic imaging modality used to evaluate diseases of the carotid arteries. [2] It is most often used to diagnose carotid artery stenosis, a form of atherosclerosis, and has the capability to assess plaque morphology and characteristics. [1] Carotid artery stenosis is a major risk factor for stroke, and risk assessment of atherosclerotic carotid plaques is a critical component of stroke prevention. Advances in imaging have allowed for risk stratification including degree of stenosis and how vulnerable the atherosclerotic plaque is to rupture. Other plaque features that contribute to stroke risk and can be evaluated by imaging are: intraplaque hemorrhage, plaque ulceration and neovascularization, fibrous cap thickness, and presence of a lipid-rich necrotic core (LNRC). [1] Carotid ultrasound is the preferred initial diagnostic test to evaluate carotid artery stenosis, [2] and can also be used to monitor response to lipid-lowering therapy. [1]

Alternative imaging modalities

Digital subtraction angiography (DSA), magnetic resonance angiography (MRA), and CT angiography (CTA) are confirmatory imaging techniques typically employed after ultrasound and prior to therapeutic intervention. DSA is the gold standard for evaluating CAS, [2] and MRI is the gold standard for carotid plaque imaging. [1]

Imaging Techniques

Duplex ultrasound

Duplex ultrasound (duplex) combines standard B-mode ultrasound and Doppler ultrasonography to evaluate both structural details of the carotid arteries and blood flow through the arteries. [2] During carotid duplex evaluation, the 2D B-mode structural image is superimposed with the doppler flow data, which provides a more realistic anatomical assessment. [2]

B-mode ultrasound is able to assess the structure of the carotid arteries and can identify areas of stenosis. B-mode is used identify stenotic lesions and to assess the echogenicity of plaques—strong correlation has been established between sonographic and histopathologic features of plaques. Plaque echolucency can signal an at-risk plaque, as it is the sonographic equivalent of a LNRC. [1] Besides, other features such as intima-media thickness, surface of the plaque and presence of ulceration are also useful in predicting the possibility of stroke or heart attack in the future. [3] Scanning through the eye can help to visualise carotid siphon (bend of internal carotid artery within the cavernous sinus) and ophthalmic artery. [4]

Doppler ultrasound allows for assessment of carotid arterial blood flow. Blood flow velocity is increased in areas of stenosis compared to normal. Therefore, doppler imaging substantially aids in the diagnosis of carotid artery stenosis by ultrasound. [2] Internal carotid artery (ICA) is located posterolateral, and larger when compared to the external carotid artery (ECA). ICA has low resistive pattern (difference between the blood velocities during heart systole and diastole) when compared to ECA. [3] ICA has sudden increase in velocity of blood flow during systole and persistent forward blood flow during diastole. [5] [6] ICA peak systolic velocity more than 125m/sec and diastolic velocity more than 40 m/sec signifies stenosis. [3]

ECA can be differentiated from the ICA by tapping superficial temporal artery of the same side. This will generate a saw-like appearance on ECA doppler. [3] Temporary reversal of the direction of flow during early diastole in ECA is normal. [7] ECA has triphasic flow pattern (forward flow in systole, reverse flow in early diastole, and forward flow in end diastole). [6]

Vertebral artery also has low resistive pattern similar to ICA. [3]

Contrast-enhanced ultrasound

Contrast-enhanced ultrasound (CEUS) is valuable because the contrast does not diffuse into surrounding tissues, and therefore all signals are intravascular. CEUS is used to assess plaque neovascularization and ulceration. Plaque enhancement on ultrasound has been proven to correlate with neovascularization, inflammation, and inflammation, and these features are associated with symptomatic carotid plaques. [1] Intravenous contrast is able to improve the performance of carotid ultrasound in diagnosing carotid artery stenosis. [2] Contraindications to the ultrasound contrast include allergy, heart failure, acute coronary syndrome, endocarditis, ventricular arrhythmia, and unstable respiration. [1] [2]

Limitations

While ultrasound is able to assess plaque morphology, it is limited in both specificity and sensitivity in assessing lipid-rich necrotic core, plaque hemorrhage, and ulceration when compared to the gold standard. [1] When diagnosing carotid artery stenosis, carotid ultrasound has a lower sensitivity than MRA but is more sensitive than CTA. However, both CTA and MRA have a higher specificity. [2]

A major limitation of carotid ultrasound is a high degree of inter-/intraobserver variability; however, computerized algorithms used for evaluation of the intima-media thickness (IMT), a measure of plaque morphology, have helped minimize the degree of variability. [2] Carotid ultrasound is dependent on operator skill, and other noted areas of limitation are poor insonation angle, poor blood flow, and deep artery location. [2] CEUS is prone to overinterpretation of vessel wall abnormalities, known as pseudoenhancement. [1]

See also

Related Research Articles

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<span class="mw-page-title-main">Atheroma</span> Accumulation of degenerative material in the inner layer of artery walls

An atheroma, or atheromatous plaque, is an abnormal accumulation of material in the inner layer of an arterial wall.

Intravascular ultrasound (IVUS) or intravascular echocardiography is a medical imaging methodology using a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter. The proximal end of the catheter is attached to computerized ultrasound equipment. It allows the application of ultrasound technology, such as piezoelectric transducer or CMUT, to see from inside blood vessels out through the surrounding blood column, visualizing the endothelium of blood vessels.

A vulnerable plaque is a kind of atheromatous plaque – a collection of white blood cells and lipids in the wall of an artery – that is particularly unstable and prone to produce sudden major problems such as a heart attack or stroke.

<span class="mw-page-title-main">Cerebral angiography</span> Angiography that produces images of blood vessels in and around the brain

Cerebral angiography is a form of angiography which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as arteriovenous malformations and aneurysms. It was pioneered in 1927 by the Portuguese neurologist Egas Moniz at the University of Lisbon, who also helped develop thorotrast for use in the procedure.

<span class="mw-page-title-main">Renal artery stenosis</span> Medical condition

Renal artery stenosis (RAS) is the narrowing of one or both of the renal arteries, most often caused by atherosclerosis or fibromuscular dysplasia. This narrowing of the renal artery can impede blood flow to the target kidney, resulting in renovascular hypertension – a secondary type of high blood pressure. Possible complications of renal artery stenosis are chronic kidney disease and coronary artery disease.

<span class="mw-page-title-main">Carotid endarterectomy</span> Surgical procedure

Carotid endarterectomy is a surgical procedure used to reduce the risk of stroke from carotid artery stenosis. In endarterectomy, the surgeon opens the artery and removes the plaque. The plaque forms and thickens the inner layer of the artery, or intima, hence the name of the procedure which simply means removal of part of the internal layers of the artery.

<span class="mw-page-title-main">Carotid artery stenosis</span> Medical condition

Carotid artery stenosis is a narrowing or constriction of any part of the carotid arteries, usually caused by atherosclerosis.

<span class="mw-page-title-main">Magnetic resonance angiography</span> Group of techniques based on magnetic resonance imaging (MRI) to image blood vessels.

Magnetic resonance angiography (MRA) is a group of techniques based on magnetic resonance imaging (MRI) to image blood vessels. Magnetic resonance angiography is used to generate images of arteries in order to evaluate them for stenosis, occlusions, aneurysms or other abnormalities. MRA is often used to evaluate the arteries of the neck and brain, the thoracic and abdominal aorta, the renal arteries, and the legs.

<span class="mw-page-title-main">Transcranial Doppler</span>

Transcranial Doppler (TCD) and transcranial color Doppler (TCCD) are types of Doppler ultrasonography that measure the velocity of blood flow through the brain's blood vessels by measuring the echoes of ultrasound waves moving transcranially. These modes of medical imaging conduct a spectral analysis of the acoustic signals they receive and can therefore be classified as methods of active acoustocerebrography. They are used as tests to help diagnose emboli, stenosis, vasospasm from a subarachnoid hemorrhage, and other problems. These relatively quick and inexpensive tests are growing in popularity. The tests are effective for detecting sickle cell disease, ischemic cerebrovascular disease, subarachnoid hemorrhage, arteriovenous malformations, and cerebral circulatory arrest. The tests are possibly useful for perioperative monitoring and meningeal infection. The equipment used for these tests is becoming increasingly portable, making it possible for a clinician to travel to a hospital, to a doctor's office, or to a nursing home for both inpatient and outpatient studies. The tests are often used in conjunction with other tests such as MRI, MRA, carotid duplex ultrasound and CT scans. The tests are also used for research in cognitive neuroscience.

<span class="mw-page-title-main">Digital subtraction angiography</span> Method for delineating blood vessels using contrast medium

Digital subtraction angiography (DSA) is a fluoroscopy technique used in interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue environment. Images are produced using contrast medium by subtracting a "pre-contrast image" or mask from subsequent images, once the contrast medium has been introduced into a structure. Hence the term "digital subtraction angiography. Subtraction angiography was first described in 1935 and in English sources in 1962 as a manual technique. Digital technology made DSA practical starting in the 1970s.

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<span class="mw-page-title-main">Fibromuscular dysplasia</span> Human arterial disease

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<span class="mw-page-title-main">Subclavian steal syndrome</span> Medical condition

Subclavian steal syndrome (SSS), also called subclavian steal steno-occlusive disease, is a constellation of signs and symptoms that arise from retrograde (reversed) blood flow in the vertebral artery or the internal thoracic artery, due to a proximal stenosis (narrowing) and/or occlusion of the subclavian artery. This flow reversal is called the subclavian steal or subclavian steal phenomenon, regardless of signs/symptoms being present. The arm may be supplied by blood flowing in a retrograde direction down the vertebral artery at the expense of the vertebrobasilar circulation. It is more severe than typical vertebrobasilar insufficiency.

<span class="mw-page-title-main">Computed tomography angiography</span> Medical investigation technique

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John David Spence is a Canadian medical doctor, medical researcher and Professor Emeritus at the University of Western Ontario. He is affiliated with the University of Western Ontario and the Robarts Research Institute, one of Canada's leading medical research organizations. Before his retirement from clinical practice in July 2022, he was also affiliated with the London Health Sciences Centre's University Hospital. He is a recognized expert in stroke prevention and stroke prevention research, with more than 600 peer-reviewed publications since 1970. He delivered more than 600 lectures on stroke prevention in 42 countries. In 2015, he received the Research Excellence Award from the Canadian Society for Atherosclerosis, Thrombosis and Vascular Biology. In 2019, he was appointed a Member of the Order of Canada, and in 2020 he received the William Feinberg Award from the American Heart Association for excellence in clinical stroke research.

Tissue Doppler echocardiography (TDE) is a medical ultrasound technology, specifically a form of echocardiography that measures the velocity of the heart muscle (myocardium) through the phases of one or more heartbeats by the Doppler effect of the reflected ultrasound. The technique is the same as for flow Doppler echocardiography measuring flow velocities. Tissue signals, however, have higher amplitude and lower velocities, and the signals are extracted by using different filter and gain settings. The terms tissue Doppler imaging (TDI) and tissue velocity imaging (TVI) are usually synonymous with TDE because echocardiography is the main use of tissue Doppler.

<span class="mw-page-title-main">Doppler ultrasonography</span> Ultrasound imaging of the movement of tissues and body fluids using the Doppler effect

Doppler ultrasonography is medical ultrasonography that employs the Doppler effect to perform imaging of the movement of tissues and body fluids, and their relative velocity to the probe. By calculating the frequency shift of a particular sample volume, for example, flow in an artery or a jet of blood flow over a heart valve, its speed and direction can be determined and visualized.

Penile ulltrasonography is medical ultrasonography of the penis. Ultrasound is an excellent method for the study of the penis, such as indicated in trauma, priapism, erectile dysfunction or suspected Peyronie's disease.

<span class="mw-page-title-main">Arterial occlusion</span>

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References

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