Daniel Makes Department Of Radiology Faculty Of Medicine University of Indonesia / Cipto Mangunkusumo Hospital Jakarta Indonesia
Ultrasound is non-invasive and more readily available than other techniques-digital subtraction angiography (DSA), computed tomography angiography (CTA) & MRA and, uniquely, it can visualise the arterial wall itself
Stroke is a significant public health problem, with an incidence of 2,9 per 1000 population in England and Wales with a recurrence rate of between 20 % and 50 % within 5 years
Thromboembolic disease is a major cause of stroke secondary to atherosclerosis, which is the formation of fibrofatty plaques within the intima of the arteries and arterioles
Atherosclerotic lesions may develop inflammatory changes, cholesterol crystals, necrotic debris, and subintimal haemorrhage If the plaque ruptures, it may release these materials as emboli and / or cause thrombus formation on the ulcerated surface, thus placing the patient at risk of cerebral thromboembolic disease
50-60 % of patients with transient ischaemic attacks (TIAs) have less than a 50 % stenosis on cerebral arteriography TIAs are followed by stroke within 5 years in 33 % of patients, the period of greatest risk being the first two weeks after a TIA
The North American Symptomatic Carotid Endarterectomy Trial (NASSCET), European Carotid Surgery Trial (ECST) and Asymptomatic Carotid Atherosclerosis Study (ACAS) have clearly demonstrated the benefit of carotid endarterectomy for symptomatic patient with > 70 % diameter stenosis
Prime indication of ultrasound is to identify flow-limiting stenoses, especially high grade stenoses (> 70 %), in symptomatic patients who are likely to benefit from carotid endarterectomy
EQUIPMENT
A high resolution linear transducer Duplex or triplex display mode option (real-time grey-scale image + spectral Dopller analysis + colour flow imaging) Adjustable wall filter, ultrasound beam angle steering, angle correction
SCANNING PROTOCOL
1. Patient position Supine Neck slightly extended Head turned away from the side being examined 2. Regions of interest Both CCAs from the origins to the bifurcations Both ICAs and ECAs as cephalad as possible Both vertebral arteries (the proximal and the interforamina segments)
Procedure
Examine the carotid arteries transversely, followed by longitudinal scans Record any plaque formation, its location, extent and morphology Quantify the degree of stenosis
Sectional planes used in examining the carotid system in the neck with duplex sonography
4. 5.
6.
Fig.11.4
PLAQUE CHARACTERISATION
Prediction of subsequent stroke by plaque morphology is controversial
Detection of ulcers in a plaque correlates better with the risk of recurrent cerebral embolism
The IMT ranges from 0.5 mm to 1.0 mm in healthy adults at all ages, values over 1.0 mm are regarded as abnormal
Detectable atherosclerotic lesions are defined as IMT > 1.2 mm whereas moderate to severe thickening is present when IMT is greater than 2 mm
Soft Plaque
Dense Plaque
Calcified Plaque
Fibromuscular Hyperplasia
Moderate stenosis
a. Color doppler image shows a color mosaic pattern representing the stenosis
b. Spectral analysis shows minimal spectral broadening and moderately elevated frequencies
Spectral Broadening
a. Minimal spectral broadening with moderate stenosis b. Complete filling of the spectral window with critical stenosis
Tortousity
a. The S-shaped tortuous internal carotid artery b. Long tortuous internal carotid artery c. Tortuosity seen with power doppler
Vertebral Artery
Atherosclerotic lesions of the vertebral arteries commonly occur at the origin of the vertebral artery
Subclavian Steal
a. Stenosis b. Occlusion
CONCLUSION
You should always increased your skill to increase your diagnostic accuracy