Introduction to Carotid Ultrasound and Transcranial Doppler Ultrasound
- Slides: 41
Introduction to Carotid Ultrasound and Transcranial Doppler Ultrasound Ryan Hakimi, DO, MS Director, Critical Care Neurology Associate Professor Department of Neurology The University of Oklahoma Health Sciences Center January 14, 2016 OU Neurology
Disclosures n Many of the slides have been adapted from slides presented at the American Society for Neuroimaging Annual Meetings by my mentors Andre Alexandrov, MD n n Zsolt Garami, MD Charles Tegeler, MD Alex Razumovsky, Ph. D FINANCIAL DISCLOSURE Ø Nothing to disclose UNLABELED/UNAPPROVED USES DISCLOSURE Ø Nothing to disclose OU Neurology
Objectives n Review the basic principles of carotid ultrasound (CUS) and transcranial Doppler ultrasound (TCD) n Illustrate the process of plaque morphology and assignment of range of carotid stenosis n Illustrate the process of determining vasospasm by TCD n Discuss some of the current applications of TCD and TCCD OU Neurology
Principles of Ultrasound n Blood flow velocity through a cross sectional area of a particular vessel (cm/s) n Blood flow velocity is directly related to Doppler shift ØIf you measure the Doppler shift you can derive the blood flow velocity § Carotid ultrasound and transcranial Doppler ultrasound can accomplish this OU Neurology
Ultrasound Physics OU Neurology
Carotid Ultrasound n Indications ØIschemic stroke or TIA ØAssessment of carotid bruit ØAssessment of carotid stenosis or occlusion ØPre-operative assessment for cardiovascular surgery ØPost carotid endarterectomy or stenting OU Neurology
Principles of Carotid Duplex n Duplex (B-mode and Doppler) Ø B-mode (brightness mode) § Grayscale, used for visualization of structures and assessment of plaque morphology • Hyperechoic (bright white: bone, calcium), causes a shadow posterior to it • Hypoechoic (black or grey: thrombus) Ø Doppler velocities (peak systolic and end diastolic) § Used to determine the direction of blood flow § Used to estimate the range of stenosis § Each lab should have own validated parameters of the velocities to be used for assignment of stenosis, not just use published values OU Neurology
Assignment of Carotid Stenosis Carotid Artery Stenosis: Gray-Scale and Doppler US Diagnosis—Society of Radiologists in Ultrasound Consensus Conference Grant et al. , 2003 OU Neurology
Transverse Right ICA B-Mode Skin surface Fat and subcutaneous tissue internal jugular vein muscle common carotid artery (Transverse Right Proximal Common Carotid Artery) OU Neurology
Longitudinal Right ICA B-mode Plaque Focal irregular, heterogeneous plaque in the R Prx ICA (Longitudinal Right Proximal Internal Carotid Artery) OU Neurology
Right ICA B-mode with Color Doppler + Flow (toward probe) - Flow (away from probe) Patient’s Head Flow (away from probe) (Right Proximal Internal Carotid Artery) OU Neurology
Right ICA Doppler Velocities + Flow (toward from probe) Patient’s Head Cardiac irregularity Flow (away from probe) - Flow (away from probe) (Right Proximal Internal Carotid Artery) OU Neurology
Report n Focal plaque in the right internal carotid artery n No hemodynamically significant stenosis demonstrated in the right internal carotid artery. n High resistance waveform pattern in the right internal carotid artery n Cardiac irregularity was noted OU Neurology
Longitudinal Left CCA B-mode Plaque with fibrous cap and lipid rich core (Longitudinal Left Mid Common Carotid Artery) Hyperechoic plaque with posterior acoustic shadowing OU Neurology
Longitudinal Left CCA B-mode Plaque Heterogeneous plaque with posterior acoustic shadowing (Longitudinal Left Distal Common Carotid Artery) OU Neurology
Longitudinal Left ICA Color Doppler Noise (sample volume picking up multiple velocity jets) OU Neurology
Carotid US vs Transcranial Doppler US n Carotid Ultrasound ØDirectly visualize the vessel ØStenosis determined by peak systolic velocity n TCD ØBlind insonation ØUses mean velocity OU Neurology
Transcranial Doppler Ultrasound OU Neurology
TCD Wave OU Neurology
OU Neurology
TCD Spectra OU Neurology
Pulsatility Indices OU Neurology
Pulsatility Indices Low PI AVM low ejection fraction aortic regurgitation High PI: intracranial atherosclerosis increased intracranial pressure OU Neurology
Insonation of Brain OU Neurology
TCD use in Carotid Occlusive Disease n Allows for evaluation of: ØCollateral flow ØCerebral embolism ØPoor vasomotor reserve i. e. progression of carotid stenosis OU Neurology
TCD use in Carotid Occlusive Disease Slide courtesy Z. Garami, MD OU Neurology
Risk of Ipsilateral Stroke: Number of Activated Collaterals (ACA, PCOM, OA) OU Neurology
Subarachnoid Hemorrhage n Detection of vasospasm Ø Clinical exam (usually somnolence or non-focal symptoms), not very sensitive Ø Daily TCD (non-invasive, 90% sensitivity, often precedes clinical vasospasm) Ø TCD or CTA can be used to screen for “plasty-able” lesions Images from 1. http: //www. spencertechnologies. com/products. html#thumb 2. www. viswiki. com/en/Transcranial_doppler, 3. http: //depts. washington. edu/uwtcdlab/images/tcd 3_lg. gif all accessed on 1/24/2010 4. Cerebrovascular Ultrasound in Stroke Prevention and Treatment OU Neurology
Thresholds for Anterior Circulation Vasospasm n Should be validated at the given center n Mild vasospasm 120 -140 cm/s, Lindegaard Ratio (MCA velocity/extracranial ICA) 3 -4 n Moderate vasospasm 140 -180 cm/s, Lindegaard Ratio (MCA velocity/extracranial ICA) 4 -6 n Severe vasospasm >200 cm/s, Lindegaard Ratio (MCA velocity/extracranial ICA) >6 n Less reliable in posterior circulation (due to greater anatomic variance) OU Neurology
Data on TCD Monitoring Courtesy Mauro Oddo, MD OU Neurology
Brain Death n Uniform Determination of Death Act ØLegally acknowledged brain death as a mechanism of death ØDefined death as: § Irreversible cessation of circulatory and respiratory functions OR § Irreversible cessation of all functions of the entire brain, including the brain stem 1. Guidelines for the determination of death: report of the medical consultants on the diagnosis of death to the President’s commission on the ethical problems in medicine and biochemical and behavioral research. JAMA 1981; 246: 2184 -2186. 2. Uniform Determination of Death Act, 12 uniform laws annotated 589 (West 1993 West suppl 1997) OU Neurology
AAN recommendations on use of ancillary testing AAN Clinician Guideline Supplement: Ancillary Testing; Update: Determining Brain Death in Adults. 2010. OU Neurology
Diagnosis of Patent Foramen Ovale (PFO) Slide courtesy Alex Razumovsky, Ph. D OU Neurology
Diagnosis of Patent Foramen Ovale (PFO) n PFO is a residual channel between the right and left atrium which originally allowed oxygenated placental blood to pass from the right to left atrium bypassing the fetal lungs n Usually closes by age 2, but can persist in 25 -30% of the general population OU Neurology
Diagnosis of PFO by TCD n Agitated saline study n Monitor the MCA Slide courtesy Z. Garami, MD OU Neurology
Diagnosing subclavian steal by TCD n Image the vertebral artery n Ischemic cuff test OU Neurology
Subclavian Steal Syndrome Slide courtesy Z. Garami, MD OU Neurology
TCCD n TCD with brightness mode (B-mode) imaging AKA: ØImaging TCD ØTranscranial color-coded Duplex (TCCD) ØTranscranial Duplex sonography (TDS) ØTriplex imaging n Adds anatomic visualization of the vasculature and surrounding structures using the grayscale of B-mode. OU Neurology
TCCD n Has benefits of TCD plus ØTCCD allows for bedside monitoring of parenchymal hematoma (hyperechoic mass) expansion ØAllows for determination of presence of IVH ØCan be used to measure midline shift ØMargins of hemorrhage degrade after 5 days ØCorrelates well with ICH volume measurement on CT head using the ABC/2 method OU Neurology
Measurement of major longitudinal (L) and sagittal (S) diameters in the axial plane and coronal plane (C) using TCCD Perez ES, Delgado-Mederos R, Rubiera M, et al. Transcranial Duplex Sonography for Monitoring Hyperacute Intracerebral Hemorrhage. Stroke 2009; 40: 987 -990. OU Neurology
Questions Thank you OU Neurology
- Difference between doppler and duplex
- Seioh
- Using a doppler ultrasound device gmat
- Christina shareef
- Digital processing
- Duplex doppler ultrasound
- Pcos ultrasound image
- Dr. lana schumacher
- Vasovagal reaction
- Pterion
- Carotid sheath contents
- Left subclavian vein
- Parotid gland vascular supply
- External carotid
- Contents of carotid sheath
- Descending hypoglossi
- Carotid terminus
- Carotid pulse location
- Hippocampus blood supply
- Anterior border of sternocleidomastoid
- Oval window opens into
- Lingual tonsil
- Carotid cavernous fistula
- Carotid cana
- Left common carotid artery
- Blood vessel man model
- Preauricular lymph node
- Lllkk
- Brain arterial supply
- Carotid cochlear dehiscence
- Carotid sinus
- Posterior auricular vein
- Organ of zuckerkandl
- Carotid artery pulse
- Normal jvp
- Eca branches
- Carotid anatomy
- An mti radar that uses amplitude fluctuations is
- Pulse doppler radar vs mti
- Laser doppler electrophoresis
- Effetto doppler - zanichelli
- Mach cone