US of Extracranial Cerebral Vessels:

A Primer
Parker Freels, MD, Sherif Elsherif, MD, Dheeraj Gopireddy, MD, Chandana
Lall, MD, Sindhu Kumar, MD, Smita Sharma, MD, Joanna Kee-Sampson, MD
 Author Affiliations:
University of Florida College of Medicine - Jacksonville
Department of Radiology
655 West 8th Street, C90
2nd Floor, Clinical Center
Jacksonville, FL 32209
Address correspondence to:
Parker Freels, MD
pdfreels@[Link]

S.E. received a travel stipend from RSNA to attend the ITAR meeting in 2021. All other authors have disclosed no relevant relationships.

Originally presented as an educational exhibit (VAEE-13) at the 2021 RSNA annual meeting.
 Background and Purpose
• Cerebrovascular disease and stroke remain leading causes of death
in the United States, with someone having a stroke every 40
seconds.
• Stroke management is also a significant financial burden, and related
costs reached upwards of $46 billion U.S. dollars in 2014–2015.
• US is a vital tool in the evaluation of a patient with suspected stroke
and other atherosclerotic disease of the extracranial
cerebrovasculature (American College of Radiology appropriateness
criteria = 8).
 Background and Purpose
• US is often performed by technologists, and radiologists may lack
experience in the acquisition of images, which limits examination
interpretation and troubleshooting.
• This presentation should be used as an educational tool and reference
when the radiologist needs to evaluate US findings of the extracranial
cerebral vessels.
• We aim to demonstrate imaging findings related to:
• Normal anatomy • Dysrhythmia
• Atherosclerotic disease • Internalization of the external carotid
artery (ECA)
• Stenosis
• Subclavian steal syndrome
• Plaque stability
• Trauma
• Postprocedural findings
• Tumor
Learning Objectives
• Discuss the proper technique for acquiring US images of vasculature
using the concepts of position, probe, and protocol.
• Appreciate the fundamentals of US physics as they apply to
extracranial cerebral vasculature.
• Recognize the major components of a vascular US examination with
description of pearls and pitfalls of acquisition.
• Detail how US can help assess hemodynamics, anatomy, and
pathologic features related to the extracranial carotid and vertebral
vasculature.
• Discuss how US can be used in the workup and management of a
patient.
US is a highly effective tool in the diagnosis of extracranial cerebrovascular disease.
It is mobile, widely available, inexpensive, noninvasive, and low risk without the use of ionizing radiation.
However, adequate image acquisition is highly dependent on the operator and patient.

Let’s review the three P’s of a carotid US examination…

PEARL
Position
The US machine and
Place the probe on
patient should both be
the neck in the
square with the
expected region of
operator’s shoulders
the carotid artery.
and in the line of sight.

Emphasize ergonomics to maximize Patient should be supine with their neck

comfort for the operator and patient. extended and supported if needed.
NOTE: An author of the exhibit is pictured here. No patients were included.
Probe
High-frequency linear array probe (arrow) used for
evaluation of the extracranial cerebral vasculature.

Don’t forget the gel!

PEARL Gel displaces air to maximize ultrasound wave penetration from probe to patient.

When localizing the carotid artery,

it’s helpful to find it in the… rotate probe

transverse plane longitudinal plane

Protocol
Understanding the physics of US is essential to protocoling and troubleshooting the examinations.

c
The probe both transmits and receives sound waves… 𝛌= f
𝛌 = wavelength
c = speed of the ultrasound wave (1540 m/sec)
f = frequency

Frequency (Hz) is inversely related to

� wavelength (𝛌).

↑ transducer frequency ↓ wavelength

� ↑ attenuation ↓ tissue penetration

Increasing the US frequency diminishes visualization of deeper structures

(the inverse is also true)
 Protocol
Ultrasound waves interact with reflective red blood cells flowing within a vessel, and this system
can be thought of as a long tube of varying caliber.

Law of Poiseuille Conservation of Mass Principle

𝝅𝚫P
n=viscosity Q = v1 x A1
(
( constan
L=length of the vessel v=velocity
Q=
8nL
(r )
4
𝚫P=pressure difference variable
t and A=area (𝝅r2)
r=radius
Q1 = Q 2 = Q 3

Same column of
The system
blood must move
through a smaller Q1 Q2 Q3 compensates with
an ↑ velocity to
area (region of
maintain flow.
stenosis).

Note.–Q indicates flow.

Protocol
Ultrasound waves interact with reflective red blood cells flowing within a vessel, and this system
can be thought of as a long tube of varying caliber.

Law of Poiseuille Conservation of Mass Principle

Flow (Q) is largely dependent on pressure and Flow through a system is constant,
vessel radius (to the fourth power): regardless of degree of narrowing:
Small changes in r mean large changes in Q. What goes in must come out.

↑ resistance to ↓ velocity distal to

flow with the stenosis as
↓ radius (to the radius returns to
fourth power) normal
Protocol
The US machine offers an overwhelming number of functions to manipulate, so let’s keep it focused…

Power

Frequency Overall gain Color Doppler

Sensitive gain

Calipers
Zoom

Depth

Pointer Scroll Capture

NOTE: These functions should be found on all modern US units.

Protocol Patient demographics
Monitor sonographic bioeffects:
Thermal index (limit 0.6)
Patient Name ID DOB
Mechanical index (limit 1.9)

Study parameters Probe

marker
Gray and color scales

Depth with focal zone set to the

midpoint (each dash = 1 cm)

The focal zone is the narrowest

point of the US beam and where
the lateral resolution is greatest.
Spectral
Doppler Spectral
waveform velocity scale

A standard protocol for an extracranial cerebral vasculature US examination includes:

gray-scale, color Doppler, and spectral Doppler images.
 *ECA = external carotid artery, ICA = internal carotid artery, CCA =

Protocol common carotid artery

Designated angle ≤60° on the spectral Doppler portion

of the examination
Doppler signal ∝ cos (θ)
!
x
Caliper in the middle of the lumen Not detectable when perpendicular
to flow because
cos (90) = ZERO
PITFALL
✓ θ ≤ 60° θ = 90°
red = TOWARDS
the probe
blue = AWAY
EC from the probe
A* Caliper in vessel center (away from the
FLOW wall) to maximize laminar flow as US
CCA* waves interact with red blood cells and ↓
ICA* artifact from peripheral turbulence

PEAK SYSTOLIC
VELOCITY (PSV) END DIASTOLE waveform above baseline
Waveform varies VELOCITY (EDV)
with cardiac cycle =
TOWARD the probe

NOTE: Most of these protocol settings are the standard convention but can be altered by the sonographer.
Protocol
Important imaging parameters to optimize in order to avoid certain artifacts:
Gain Color Gain Spectral Doppler Scale
Color blooming artifact

Too
High
x
x
Aliasing: scale is too
Too narrow so data wrap around
Low the set parameters
(arrows).

✓
Aliasing is improved by
Just increasing the velocity
Right scale or pulse repetition
frequency.
Protocol
Important imaging parameters to optimize in order to avoid certain artifacts:
Doppler Angle Spectral Doppler Waveform

Too
High
x θ = 90°
signal barely detectable

Too
Low x θ = -60° with opposite
waveform direction (below
the baseline)

✓
Just
Right θ ≤ 60°
Protocol
Important imaging parameters to optimize:

Caliper Placement
Especially within tortuous anatomy, placing the caliper in the center of the vessel parallel to blood flow can be
challenging. When the caliper is inappropriately placed, Doppler readings can be falsely elevated, and artifact

x
may result.

✓
VS !
PITFALL
ICA
Normal Vessel Analysis

CCA

ECA
 Normal Vessel Analysis

CCA

Intima
• Largest-caliber vessel, which Media
bifurcates into ICA and ECA Adventitia
• Mix of ICA and ECA waveforms
• Moderate diastolic flow but not as
much as ICA
 Normal Vessel Analysis

Dicrotic notch is a normal finding and sometimes seen in

transition from systole to diastole with closure of the aortic
valve. It can also be seen in valvular disease.
ICA

• Continuous diastolic flow maximizes blood

supply to the brain
• Low-resistance waveform
• Broad systolic peak
• No spectral broadening
 Normal Vessel Analysis

ECA

• Branched, small-caliber vasculature

supplying the scalp and face
• High-resistance system with a triphasic
waveform and increased velocities
• Sharper, narrower systolic peak with very
little flow during diastole
 Normal Vessel Analysis

Vertebral Artery

• Additional blood supply to the brain,

similar to ICA
• Low-resistance waveform with
sustained diastolic flow
• Systolic velocities range from 41–64
cm/sec NOTE: Some institutions include the
subclavian arteries in their imaging protocol.
Plaque Characterization PEARL

Plaque is most often eccentric, so multiple projections are needed until the best image plane is selected.

x ✓

! US is a two-dimensional representation of a three-dimensional disease process.

CT or MRI are better modalities to fully characterize plaque.
PITFALL
Plaque Characterization
The Three S’s:
Sonolucency*, Surface, Stability
European Consensus for Grading of Plaque
Grade 1 Uniformly echolucent* +/- echogenic cap Heterogeneous = Unstable plaques with
High risk for neurologic events
Grade 2 Predominantly echolucent* with <50% echogenic
Grade 3 Predominantly echogenic plaque with <50% echolucent*
Grade 4 Uniformly echogenic Homogeneous = Stable plaques with
Grade 5 Calcified plaques lower risk for neurologic events

• For plaque characterization, the artery should be imaged in both gray scale and color Doppler.
• Color Doppler imaging may obscure plaque because of bleeding artifact.
• By evaluating the sonographic three S’s when assessing extracranial vasculature, one can
determine the plaque’s characteristics and predict risk of neurologic events. *Anechoic.
Plaque Characterization: Calcified Plaques
The Three S’s:
Sonolucency, Surface, Stability

• Uniformly hyperechoic plaques correlate with

more calcified stable atherosclerotic disease.
• However, a densely calcified plaque can mask
stenosis if it is longer than 1–2 cm.
• If the calcified segment is less than 1–2 cm, !
elevated velocities and poststenotic turbulence are PITFALL
Gray-scale US image shows large calcified suggestive of hemodynamically significant stenosis.
plaque (arrow) in the right carotid bulb
causing posterior acoustic shadowing.
Plaque Characterization: Soft Plaques
The Three S’s:
Sonolucency, Surface, Stability
A. B. C.

(A) Gray-scale and (B) color Doppler US images show predominantly anechoic plaque within the mid left ICA
(arrows). (C) Spectral Doppler US image shows significantly elevated PSV.
• Hypoechoic or anechoic (soft) plaque correlates with recent hemorrhage or thrombus
versus lipid core.
• Color Doppler US improves detection with separation between the color-filled lumen
and the vessel wall.
• Noncalcified plaque = instability → increased risk of embolism and neurologic events.
Plaque Characterization: Soft Plaques
The Three S’s:
Sonolucency, Surface, Stability
A. B.

Heterogeneous plaque (arrows) in the left CCA in another patient with focal depression
on the (A) gray-scale US image and confirmed on the (B) color Doppler US image.
• Surface irregularity is a negative predictor for plaque stability when evaluating
atherosclerotic disease.
• Characterization of plaque surface is improved with color flow analysis (above).
• Although US has poor sensitivity for ulceration detection, it can still be used to
evaluate plaque surface characteristics.
Criteria for Diagnosis of ICA Stenosis

Society of Radiologists in Ultrasound

Consensus Conference (SRUCC) Criteria: • Published references should be used as guidelines
Primary parameters: for clinical management and study protocol.
• Detection of plaque • NASCET criteria for angiography compares the
• PSV in the ICA size of the diseased lumen with the uninvolved
Secondary parameters: distal vessel lumen to measure carotid stenosis.
• EDV in the ICA • NASCET criteria should be used when
• ICA/CCA PSV ratios angiographic findings are correlated with US
findings.
Normal Values:
• For PSV criteria, detection reaches:
• ICA PSV <125 cm/sec
• 98% sensitivity, 88% specificity for 50% stenosis.
• ICA/CCA ratio <2
• 90% sensitivity, 94% specificity for 70% stenosis.
• ICA EDV <40 cm/sec
*NASCET = North American Symptomatic Carotid Endarterectomy Trial
Diagnosis of ICA Stenosis according to SRUCC Criteria
<50% stenosis 50%–69% stenosis >70% stenosis
PSV <125 cm/sec PSV 125–230 cm/sec PSV >230 cm/sec
EDV <40 cm/sec EDV 40–100 cm/sec EDV >100 cm/sec
ICA/CCA ratio <2.0 ICA/CCA ratio 2.0–4.0 ICA/CCA ratio >4.0

Minimal plaque detected Large calcified plaque Predominantly hypoechoic

with shadowing plaque

Secondary SRUCC Criteria

Parameters May Be Used When:
• PSV not representative of disease extent
• Tandem lesions manifest
• Contralateral high-grade stenosis
• Visual discrepancy plaque burden and
ICA PSV
• ↑ CCA velocity
• Hyperdynamic cardiac function
PSV 123.7 PSV 155.7 PSV 450
EDV 18.7
ICA/CCA: 1.35
EDV 42.7
ICA/CCA: 2.69
EDV 169.2
ICA/CCA: 7.42
• ↓ cardiac output (CO)
Could ICA Stenosis Be Under- or Overestimated?
Changes in

Underestimate
CO
Patients with ↓ CO will have falsely ↓ PSV for the degree of stenosis.

Measuring
PSV within the CCA is more accurately measured at its distal aspect, 2–4 cm proximal
the proximal
CCA PSV to the bifurcation.

↑ PSV in the ICA contralateral to a high-grade stenosis or occlusion if the vessel is

Overestimate
Contralateral
stenosis the major supplier of collateral flow.

Vessel The ICA PSV may be overestimated in tortuous vessels secondary to ↑ PSV and
tortuosity difficulty in setting a correct Doppler angle.

Therefore, both the gray-scale and color Doppler appearance of the carotid vessels, including evaluation
of the plaque burden and degree of luminal narrowing, are critical for assessment of suspected stenosis.
Updated Criteria by the Intersocietal Accreditation Commission (IAC)

• New IAC guidelines suggest SRUCC criteria significantly overestimates stenosis

related to ICA lesions.
• The stricter and more accurate IAC criteria for moderate lesions should be
considered in future US protocols.
• However, there currently are insufficient data to change the criteria in evaluation of severe
stenosis.

Existing SRUCC Criteria New IAC Criteria

Moderate (50%–69%) Moderate (50%–69%)
stenosis stenosis
PSV 125–230 cm/sec PSV >180 cm/sec
EDV 40–100 cm/sec EDV 40–100 cm/sec
ICA/CCA ratio 2.0–4.0 ICA/CCA ratio >2.0
Severe (>70%) stenosis Severe (>70%) stenosis
PSV >230 cm/sec Future research is required.
EDV >100 cm/sec
ICA/CCA ratio >4.0
 Spectral Broadening
A. B. C.

(A) Gray-scale and (B) color Doppler US images with marked narrowing of the left proximal ICA by anechoic noncalcified
atherosclerotic plaque (arrows). (C) Elevated PSV and spectral broadening, suggesting hemodynamically flow limiting stenosis
and downstream turbulent flow.

• A filling in of the spectral window due to an increased range of velocities, related to turbulent flow in
poststenotic vessels

• Heterogeneous sampling from turbulent reflective red blood cells, contributing to more variable and wider
range in velocity data at Doppler US evaluation
• It may be related to technical factors including: Minimize artifactual spectral broadening by:
• Tortuous vessels
• ↑ Gain settings • ↓ Gain settings.
• Procedural changes
• ↑ Vessel wall motion • ↓ Size of the Doppler US sample volume.
• ↑ Velocities contralateral to a
severely diseased or occluded ICA
 What is the role of US in the management of
extracranial cerebrovascular disease?

It is used in the initial assessment in patients with suspected atherosclerotic

disease of the extracranial vasculature but is also useful during the treatment
phase and follow-up.
 Recurrent syncope and right-sided weakness in a 72-year-old woman
Carotid US is commonly used as an initial examination.

=
>70%
stenosis
Mixed atherosclerotic plaque with luminal narrowing of Elevated PSV with spectral broadening
the left ICA (arrows)

US may prompt further workup with CT or MR angiography.

Severe narrowing of the

left ICA seen on axial (left)
and sagittal (middle, right)
CT angiographic images
just distal to its origin,
consistent with
approximately 80%
stenosis by NASCET
criteria (arrows).
>50% stenosis + symptoms OR >70% stenosis requires intervention (endovascular stent placement or endarterectomy)

Before intervention: critical stenosis of the Following stent placement: increased diameter of
proximal left ICA (arrow) diminishing flow the left ICA (arrow) with markedly improved overall
distally on conventional angiograms. distal perfusion on conventional angiograms.
Restenosis most commonly develops from neointimal hyperplasia. Postprocedural results can be
monitored with follow-up US examinations.

Stent
PSV = 55.5 cm/sec
EDV = 19.1 cm/sec
ICA/CCA ratio =
<2.0
Follow-up US images in a patient with a left ICA stent (arrow). Hemodynamics returned to normal.
 Carotid Doppler US after Intervention

• A vessel with a stent may decrease compliance of the

A. B. C.
vessel, falsely elevating PSV.
• No widely accepted US criteria for evaluation after
intervention
• Lal et al12 suggest the following criteria:

Stenosis PSV ICA/CCA ratio

D.
>20% ≥150 cm/sec ≥2.15
>50% ≥220 cm/sec ≥2.7
>80% ≥340 cm/sec ≥4.15
(A) Right ICA angioplasty and stent placement with residual 30% stenosis (arrow)
on an angiographic image. Six months later, (B) gray-scale, (C) color Doppler, and
(D) spectral Doppler US images show elevated PSV within the right mid ICA,
consistent with less than 50% in-stent stenosis.
 Lightheadedness and palpitations in a 54-year-old woman. No focal neurologic deficits.

The patient initially underwent evaluation with carotid US examination.

A. B.

(A) Patent vessels show scattered atherosclerotic disease throughout the carotid vasculature. (B) Spectral
Doppler US image of the ICA shows irregular heart rate, suggestive of dysrhythmia (double-sided arrows).

Irregularities in the morphology or frequency of the carotid artery Doppler waveform can detect
alterations in cardiac function and suggest dysrhythmia.

Low CO, aortic valvular disease, or cardiovascular devices may also alter the carotid Doppler waveforms.

Follow-up electrocardiography should be performed.

12-lead electrocardiography confirmed atrial fibrillation.

 Degree of ICA Occlusion
Near Occlusions Occlusions
• Treated surgically given the high stroke risk (11% per • Nonoperative management
year)
• No spectral, color, or power Doppler signals within the lumen
• PSV may decrease to normal limits or lower in severe ± internal echogenic calcified plaque
stenosis.
• High-resistance waveform results if the lesion progressed
• More sensitive power Doppler US can help visualize quickly (may be normal if it is chronic).
the very small lumen of a near occlusion.

A. B. A. B.

C. (A) Gray-scale, (B) color

C.
Doppler, and (C) spectral
Doppler US images of the
proximal left ICA show
significant plaque causing
critical stenosis >70%
(A) Gray-scale, (B) color Doppler, and (C) spectral
(arrows).
Doppler US images demonstrate occlusion of the
ICA (arrows).
 Internalization of the ECA

A. B. C. G.

D. E. F.

(A) Gray-scale and (B) color Doppler US images in a patient with suspected right ICA occlusion (arrows). (C) There are dampened spectral
Doppler waveforms upstream. (D) Gray-scale and (E) color Doppler US images of the right ECA show patent flow (arrows). (F) Altered ECA
spectral waveforms show broad systolic peaks (double-headed arrows), low resistance, and increased diastolic flow (arrows), resembling an ICA
waveform. (G) CT angiographic image confirms occlusion of the right ICA from atherosclerotic disease (arrow).

• In cases of ICA occlusion, low-resistance collateralization occurs between the ICA and ECA.
• Internalization of the ECA decreases vascular resistance and provides continuous diastolic flow to maximize
perfusion to the brain through the alternate collateral pathway.
False-Positive Diagnosis of ICA Occlusion
A. B. C.
Contributing Factors:
• Carotid artery is obscured by
calcified plaque
• Poor image quality
• Slow trickle flow from near- total
occlusion
• Low gain
(A) Plaque obscures evaluation of the left proximal ICA (arrows). (B) Axial CT angiographic image
of the neck shows heavy calcific atherosclerosis with vessel irregularity in the bilateral ICAs
(arrows). (C) Findings on sagittal CT angiographic image rule out occlusion and correlate with
approximately 60% stenosis (arrows).

When is CT angiography or MR angiography indicated?

If there is concern for occlusion at US
! OR
when the sonographic results are equivocal.
PITFALL
CCA Stenosis
• PSVs are inconsistent and typically diminish A. B.
toward the bifurcation.
• If PSV doubles across a lesion (CCA lesion/CCA
normal ratio = PSV in the lesion or PSV
immediately before or downstream from the
lesion) or PSV >180 cm/sec, ≥50% stenosis.
C.
• CCA origins not seen at US.
• Stenosis suggested with asymmetric CCA PSVs,
tardus parvus waveforms (see below), or
turbulence downstream to the stenosis.
(A) Gray-scale, (B) color Doppler, and (C) spectral Doppler
• CT or MR angiography recommended. images show mildly increased PSV in the left CCA,
consistent with <50% stenosis.

D. E. (D) Color Doppler image shows the

ICA in a different patient. (E) Spectral
Doppler image shows prolonged
systolic upstroke and low amplitude,
consistent with a tardus parvus
waveform and upstream stenosis.
 Dizziness and left arm weakness in a 48-year-old man.
First step: review history and perform physical examination
Worsening symptoms with exercise
Asymmetrically diminished pulses in the left upper extremity and ↓ strength in the left arm with exertional maneuvers

Follow-up US of the extracranial cerebral vasculature was performed.

A. B. (A) Reversal of color flow in the
left vertebral artery (arrow).
(B) Spectral Doppler image
shows a waveform entirely
below the baseline, confirming
flow reversal.

PEARL

C.
(C) In another patient, the “bunny waveform”
results from a steep deceleration during systole
after a drop in pressure in the stenotic
subclavian artery and is seen in the early
phase of the subclavian steal phenomenon
prior to occlusion.
Follow-up CT angiography of the neck was performed for improved evaluation of the proximal cervical
vasculature and aortic arch.

Findings on sagittal CT Reversed flow in the

angiographic image confirm Normal antegrade
flow in the left vertebral artery
heavy atherosclerotic disease
near the origin of the left unaffected right
subclavian artery (arrow). vertebral artery
These imaging findings support
the suspected diagnosis.
The left subclavian
artery is predominantly
supplied by the
Subclavian steal syndrome is a clinical diagnosis and results from ipsilateral vertebral
artery.
severe stenosis versus occlusion of the proximal subclavian artery
causing reversal of flow in the ipsilateral vertebral artery.
Signs and symptoms
Dizziness or vertigo and asymmetric upper extremity blood pressure (especially after
exercise in the affected limb)
Obstructed flow at
More common on the left (will not occur if the vertebral artery has a direct origin from the the subclavian
aorta) artery origin
Blood is diverted away from the brain. Degree of cerebral ischemia or neurologic deficit is
dependent on collateralization of flow.

Treatment = endovascular versus surgical intervention

 Other Extracranial Cerebral Vascular Pathologic Conditions…
Carotid Dissection Pseudoaneurysm
• CCA dissection usually originates in the aortic arch • Defect in the arterial wall with circulating to-and-fro blood flow
with extension to the carotid bifurcation and the ICA. pattern in the pseudoaneurysm neck and yin-yang flow confined
to the pseudoaneurysm.
• ICA dissection normally occurs in the mid to distal
ICA, most commonly following trauma. • In comparison to a true aneurysm, pseudoaneurysm does not
involve all three layers of the vessel wall.
• Smooth tapering stenosis on US images with an
• Etiology: infection, trauma, or iatrogenic (eg, percutaneous
TRAUMA

echogenic intimal flap

catheterization)

Gray-scale and color Doppler images show an echogenic Pseudoaneurysm of the right ICA with yin-yang flow on color Doppler
dissection flap within the CCA (solid arrow) with filling of the images (arrows).
false lumen (dashed arrow).
 US can also help evaluate other extracranial cerebral vascular pathologic conditions…

A. B. C. D.
TUMOR

(A) Gray-scale and (B) color Doppler images show a solid hypoechoic mass with internal vascularity (arrows) splaying the
carotid vessels at the bifurcation, consistent with a glomus body tumor. (C) Contrast-enhanced CT image shows a
heterogeneously enhancing mass centered within the left carotid space. (D) Axial contrast-enhanced T1-weighted MR
image shows similar findings (arrows), confirming the diagnosis.

Carotid body tumors are rare highly vascular glomus tumors of low malignant
potential seen at the level of the carotid bifurcation, classically splaying the vessels.
Summary
• In the era of advanced imaging, US remains an invaluable tool due
to its relative low risk and cost and significant diagnostic yield.
• However, it is highly dependent on the operator and patient.
• Awareness of the subtle sonographic nuances and parameters is
imperative for accurate interpretation by the radiologist.
• US remains an important modality in the diagnosis and
management of extracranial cerebral vasculature.
• The radiologist should use this presentation as a reference tool
when evaluating US examinations of extracranial vasculature.
• There is no substitute for practice, so radiologists should also take
every opportunity to image patients themselves!
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 Suggested Readings
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A special thank you to…

• Our US technologist Makailee Mausling, RDMS, RVT

• Creative design consultant and artist Georgia Lee Freels