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Carotid Pathology

Carotid Pathology. Carotid - Pathology. Plaque characteristics and grading Stenosis Thrombosis/Occlusion Aneurysm Carotid Body Tumor Dissection Fibromuscular displasia Vertebral / Subclavian steal. Pathology - Plaque. Fatty Streaks Mild, moderate, or severe

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Carotid Pathology

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  1. Carotid Pathology

  2. Carotid - Pathology • Plaque characteristics and grading • Stenosis • Thrombosis/Occlusion • Aneurysm • Carotid Body Tumor • Dissection • Fibromuscular displasia • Vertebral / Subclavian steal

  3. Pathology - Plaque • Fatty Streaks • Mild, moderate, or severe • Homogenous vs. heterogeneous • Smooth vs irregular • Calcified • Ulcerative • Occlusion

  4. Plaque Characteristics Smooth and Homogeneous

  5. Plaque Characteristics Heterogeneous/Irregular/Calcified

  6. Plaque Characteristics Heterogeneous/Irregular/Calcified

  7. Plaque Ulceration Sonography detection of ulcerations remains controversial. With sensitivities ranging from <30% to more than 90%.

  8. Plaque Ulceration DX: 2x2 mm crater; filled with color.

  9. Carotid Stenosis • Velocity flow remains normal until lumen diameter is reduced by 50% (Spectral Broadening). • Moderate (50-70%) a pressure gradient exists throughout diastole. • Severe (70-90%) increased pressure gradient = Peak Systolic & End Diastolic Velocities with Poststenotic Turbulence.

  10. Hemodynamicaly Significant Stenosis • Greater than 70% diameter or 90% cross-sectional area reduction. • Exhibits Poststenotic Turbulence. • Peak Systolic Velocity 250 cm/sec or greater “JET” flow & End Diastolic Velocity greater than 100 cm/sec

  11. ICA - Stenosis

  12. ICA Stenosis

  13. Stenosis

  14. Stenosis

  15. Critical Stenosis Spectral Broadening with Forward and Reverse Components (Post Stenotic Turbulence)

  16. Critical Stenosis

  17. Critical Stenosis

  18. Critical Stenosis

  19. Critical Stenosis Elevated PSV/EDV

  20. Color Hallmarks Indicating Hemodynamic Stenosis Post-stenotic turbulence useful for detecting >70% decreased diameter. Forward & reverse flow components.

  21. Color Hallmarks Indicating Hemodynamic Stenosis Tissue vibration caused by severe obstruction (Mosaic pattern).

  22. Proximal Disease Right CCA/ICA

  23. Proximal Disease Tardus-Parvus/Monophasic Waveforms: Right CCA/ICA

  24. Distal Disease ICA Occlusion Ipsilateral Internalized ECA Ipsilateral High Resistance CCA Ipsilateral High Resistance ICA

  25. Indirect Signs of Stenosis/Obstruction Stenosis obscured Jet by Calcification

  26. Indirect Signs of Stenosis/Obstruction Poststenotic Waveform Indicates >70% Diameter Reduction

  27. Indirect Signs of Stenosis/Obstruction High Resistance Distal Disease CCA

  28. Indirect Signs of Stenosis/Obstruction Tardus-Parvus Proximal Disease CCA

  29. Subtotal ICA Occlusion Low Flow Setting String Sign Power Doppler

  30. Subtotal ICA Occlusion Ipsilateral High Resistance ICA Ipsilateral High Resistance CCA Power Doppler

  31. Detection ICA Occlusion: • Absent flow by spectral & color imaging • Thrombus completely filling the lumen • Reverse flow in segment proximal to ICA or CCA

  32. Detection ICA Occlusion: • High Resistance waveforms in ipsilateral CCA/Proximal ICA • Internalization of ECA • Increased velocities in contralateral CCA

  33. Internal Carotid Artery Occlusion StumpFlow Thrombus StumpFlow ICA High Resistance CCA Color Void/Low Flow Internalization ECA

  34. ICA Occlusion

  35. ICA Occlusion

  36. ICA Occlusion

  37. ICA Occlusion

  38. CCA Occlusion • Clinical features similar to ICA Occlusion • Incidence 1-5% of Cases (Rare) • Left side predilection (89%)

  39. Common Carotid Artery Occlusion • ECA supplies ICA via Carotid Bifurcation • ECA flow is reversed • Ipsilateral Intracranial ICA not fully compensated by: • Vertebrobasilar Circulation • Contralateral ICA • Ipsilateral ICA flow is Antegrade/Damped

  40. CCA - Occlusion Sonographic Findings Absent CCA Flow by Color Doppler

  41. CCA - Occlusion Sonographic Findings Absent CCA Flow by Spectral Doppler

  42. CCA - Occlusion ECA/ICA Reverse Flow Directions

  43. CCA - Occlusion Sonographic Findings Antegrade/Damped ICA Flow

  44. CCA - Occlusion Sonographic Findings Reverse Flow in ECA by Color/Spectral

  45. CCA - Occlusion Sonographic Findings Reverse Flow in ECA by Color/Spectral

  46. Carotid Body Tumor • Rare tumors, 1 in 30,000 in general population • Malignant potential 2-10% of cases • Palpable, painless slow growing neck mass

  47. Carotid Body Tumor • Other signs; pain, headache, hypertension, Horner’s syndrome • Highly vascular located between the ICA & ECA • Blood supply via the ECA

  48. Carotid Body Tumor Sonographic Findings ICA Solid well-circumscribed Hypoechoic Mass T Splaying of ICA/ECA ECA ECA Blood Supply

  49. Carotid Body Tumor ICA Highly Vascular T ECA

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