Assessment of Extra
Cranial Cerebral
Circulation
Carotid Ultrasound
Study Protocol
1. Identification of vessels
2. Spectral Waveform
3. Measurements
a. Velocity measurements
b. Intima-Media Thickness (IMT) measurement
GRAYSCALE
COMMON CAROTID ARTERY (CCA)
• Transverse scan
Common Carotid A
• Origin
• Right CCA
• Easy
• Linear transducer
or
Subclavian A Brachiocephalic Trunk
GRAYSCALE
COMMON CAROTID ARTERY (CCA)
• Transverse scan Common Carotid A
• Origin
• Right CCA
• Easy
• Linear transducer
• Left CCA
• Difficult
• Microconvex / sector
Aortic Arch
GRAYSCALE
COMMON CAROTID ARTERY (CCA)
• Transverse scan
• Common Carotid
Artery (CCA) IJV
CCA
GRAYSCALE
COMMON CAROTID ARTERY (CCA)
• Transverse scan
• Common Carotid Artery IJV
Bifurcation ECA
ICA
GRAYSCALE
COMMON CAROTID ARTERY (CCA)
• Transverse scan
• Common Artery
Bifurcation ECA ICA
GRAYSCALE
COMMON CAROTID ARTERY (CCA)
• Transverse scan
• Common Artery
Bifurcation ECA ICA
Normal flow separation
Eddy currents of blood flow or vortexes
GRAYSCALE
COMMON CAROTID ARTERY (CCA)
• Transverse Scan:
• The CCA should be scanned along
its whole length in transverse
section up to bifurcation and
along the ICA and ECA as high up
the neck as can be seen. This
allows to ascertain
• The level and orientation of
ECA
carotid bifurcation ICA
• First indication about presence
and location of any arterial
disease
• Color Doppler shows normal flow
separation at bifurcation
Normal flow separation
Eddy currents of blood flow or vortexes
GRAYSCALE
COMMON CAROTID ARTERY (CCA)
• Longitudinal Scan:
• Helps determine the examination
plane necessary for optimal
longitudinal scans by the course
of the vessels demonstrated on ECA
transverse study
CCA
• Branches Normal CCA
ICA
• Anterior Approach
• ECA (Anterior Near)
• ICA (Posterior – away)
• Posterior Approach
• ICA (Anterior - near)
• ECA (Posterior – away)
GRAYSCALE
COMMON CAROTID ARTERY (CCA)
• Longitudinal Scan:
• Helps determine the examination
plane necessary for optimal
longitudinal scans by the course
of the vessels demonstrated on
transverse study
ECA
• Branches CCA
• Anterior Approach
ICA
• ECA (Anterior Near)
• ICA (Posterior – away)
• Posterior Approach
• ICA (Anterior - near)
• ECA (Posterior – away)
GRAYSCALE
EXTERNAL CAROTID ARTERY (ECA)
• Longitudinal Scan:
• Helps determine the examination
plane necessary for optimal
longitudinal scans by the course
of the vessels demonstrated on
transverse study
• Branches Vein
CCA
• Anterior Approach
• ECA (Anterior Near)
ECA
• ICA (Posterior – away)
• Posterior Approach
• ICA (Anterior - near)
• ECA (Posterior – away)
COLOR DOPPLER
• Longitudinal Scan:
• Helps determine the examination
plane necessary for optimal
longitudinal scans by the course
of the vessels demonstrated on
transverse study
• Branches
• Anterior Approach
• ECA (Anterior - near)
• ICA (Posterior – away)
• Posterior Approach
• ICA (Anterior - near)
• ECA (Posterior – away)
COLOR DOPPLER
• Longitudinal Scan:
• Helps determine the examination
plane necessary for optimal
longitudinal scans by the course
of the vessels demonstrated on
transverse study
• Branches
• Anterior Approach
• ECA (Anterior – near)
• ICA (Posterior – away)
• Posterior Approach
• ICA (Anterior - near)
• ECA (Posterior – away)
COLOR DOPPLER
ICA CCA
ECA
FMD
SPECTRAL DOPPLER
ICA CCA
ECA
Temporal artery tap (TT)
SPECTRAL DOPPLER
• Internal Carotid Artery (ICA)
• Low resistance waveform with a
• Clean spectral window beneath the trace
• External Carotid Artery (ECA)
• High resistance waveform
• Flow velocities rise sharply in systole and
fall rapidly during diastole
• May have retrograde flow in diastole
• Common Carotid Artery (CCA)
• Low resistance waveform with a
• Clean spectral window beneath the trace
• CCA waveform is a combination of both ICA
and ECA waveforms
SPECTRAL DOPPLER
• ICA: • ECA: • CCA:
• Branches arising from it
• Pulsatile walls
• Often posterolateral to ECA. (Trv. plane) • Smaller caliber than ICA
• CCA is posterior and medial to IJV
• “Swishing” audio signal with relatively high systolic
• When in Long plane it runs velocities and low diastolic velocities. • Smaller caliber than jugular vein
posterolaterally, moving away from the • More pulsatile as it supplies high resistance vascular bed • Higher PSV than ICA / Systolic peak and
transducer while ECA remains close to of face, neck and scalp, so a little diastolic flow diastolic endpoints in between that of
• The ECA may show triphasic spectrum that includes a
transducer over a longer distance reverse flow component external and internal carotid arteries
• Higher diastolic flow due to low • ECA shows positive "temporal tap" (i.e., will produce an on spectral analysis
oscillations of ECA spectral waveform)
intracranial peripheral resistance • Once the ECA has been positively identified then it can
be assumed that the other branch is the ICA
• Branching vessel – flow
separation
• Abrupt change in vessel
diameter – Carotid bulb
• Branching vessel – flow
separation
• Abrupt change in vessel
diameter – Carotid bulb
ICA ECA
ICA
ICA
CCA
ECA
CCA in ICA Occlusion ICA Distal to proximal Stenosis ICA in MCA Occlusion ECA in ICA Occlusion
(Externalization of CCA – Tardus-parvus Waveform (High resistance flow in (Internalization of ECA)
lack of diastolic component) non diseased ICA origin)
