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Vascular > Chapter 7: The Extracranial Duplex Ultrasound Examination > Flashcards

Chapter 7: The Extracranial Duplex Ultrasound Examination Flashcards

1
Q

an abnormal “blowing” or “swishing” sound heard with a stethoscope while auscultating over an artery, such as the carotid. The sound results from vibrations that are transmitted through the tissues when blood flows through a stenotic artery.

A

bruit

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2
Q

A slight dilation involving variable portions of the distal common and proximal internal carotid arteries, often including the origin of the external carotid artery. This is where the baroreceptors assisting in reflex blood pressure control are located.

A

carotid bulb

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3
Q

Most commonly defined as the angle between the line of the Doppler ultrasound beam emitted by the transducer and the arterial wall (also called the “angle of insonation”). This is a key variable in the Doppler equation used to calculate flow velocity.

A

Doppler angle

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4
Q

The location along the ultrasound beam where a pulsed Doppler detects flow. The size and the depth of the sample volume can be adjusted by the examiner to allow evaluation of flow at any site in the B-mode image.

A

sample volume

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5
Q

A signal processing technique that displays the complete frequency and amplitude content of the Doppler flow signal. The spectral information is usually presented as waveforms with frequency (converted to a velocity scale) on the vertical axis, time on the horizontal axis, and amplitude indicated by a grayscale.

A

spectral analysis

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6
Q

An increase in the “width” of the spectral waveform (frequency band) or “filling in” of the normally clear area under the systolic peak. This represents turbulent blood flow associated with arterial lesions.

A

spectral broadening

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7
Q

An episode of stroke-like neurologic symptoms that typically lasts for a few minutes to several hours and then resolves completely. This is caused by a temporary interruption of the blood supply to the brain in the distribution of a cerbral artery.

A

transient ischemic attack (TIA)

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8
Q

Normal ICA PSV

A

<125 cm/s

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9
Q

Extensive plaque, often with acoustic shadowing due to calcification

PSV >125 cm/s and EDV > 140 cm/s

A

Severe (80-99%) ICA stenosis

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10
Q

Retrograde of “hesitant” flow in the ipsilateral vertebral artery

A

subclavian steal

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11
Q

brachial systolic pressure gradient >15 mmHg

A

Subclavian steal

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12
Q

minimal or no spectral broadening; flow separation present in the carotid bulb

A

Normal ICA

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13
Q

spectral broadening during deceleration phase of systole only

A

1% - 15% occlusion

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14
Q

spectral broading throughout systole; plaque

A

16-40% occlusion

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15
Q

mark spectral broadening; plaque

A

80-90% occlusion

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16
Q

No flow signal in the ICA; decreased or absent diastolic flow in the ipsilateral CCA; plaque or thrombosis in the ICA lumen; diffusely increased PSV in contralateral carotid system

A

100% occlusion

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17
Q

Primary goal of noninvasive testing for extracranial cerebrovascular disease

A

identify patients who are risk for stroke due to athersclerotic plaque

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18
Q

Secondary goal on nonvasive testing for extracranial cerebrovascular disease

A

document progressive disease in patients already known to be at risk or recurrent stenosis after intervention

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19
Q

Major indications Carotid exam

A

asymptomatic neck bruit
hemispheric cerebral or occular transient ischemic attacks
history of stroke
screening before major peripheral vascular

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20
Q

Only about ___ of bruits are related to high-grade internal carotid stenoses

A

1/3

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21
Q

sometimes referred to as a “mini stroke?

A

TIA

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22
Q

characterized by
focal weakness
numbness
aphasia

A

TIA

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23
Q

also known as cerebrovascular accident

A

stroke

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24
Q

provide best image resolution; most options for Doppler angle correction

A

linear array transducer 12-3MHz

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25
Q

Scale should be set in the range of ______ cm/s.

A

20-40

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26
Q

typically located anterior and medial to ICA

A

ECA

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27
Q

can be identified as the artery with multiple branches beyond carotid bifurcation

A

ECA

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28
Q

visible as a thin gray-white line on innermost part of wall

A

intima-media layer

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29
Q

Plaque most commonly forms at _______, ______, ______, and ______

A

common carotid bifurcation
distal CCA
proximal ICA
proximal ECA

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30
Q

uniform in appearance; often of relatively low echogenicity; correlates with high lipid content and presence of fibro fatty tissue; smooth appearing fibrous cap

A

homogeneous plaque

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31
Q

may be composed of fatty material and areas of calcium that tend to cause brighter echoes and acoustic shadowing.

A

mixed echogenicity plaque

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32
Q

occurs when calcium attenuate the transmission of ultrasound

A

acoustic shadowing

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33
Q

can cause plague to become “unstable”; can expand, increasing both degree of stenosis and potential to produce emboli to brain; ulceration or rupture of fibrous cap

A

intraplaque hemorrhage

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34
Q

disruption of the intima with blood from the true lumen flowing between layers of vessel wall

A

intraluminal defects

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35
Q

referred to as arterial dissection

A

intraluminal defects

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36
Q

Where do spontaneous arterial dissections usually occur?

A

aortic root

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37
Q

most often related to progressive atherosclerotic plaque, cardiogenic emboli, trauma, or dissection

A

carotid artery thrombosis

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38
Q

any adverse patient condition that is induced inadvertently by a provider in course of diagnostic procedure or therapeutic intervention

A

iatrogenic injury

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39
Q

provide hemodynamic information for interpretation of flow changes proximal to, at, and distal to insonated location

A

Doppler Spectral

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40
Q

provides most reliable means for assessing vessel patency and classifying degree of stenosis

A

spectral Doppler

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41
Q

CCA, ICA, ECA Normal Doppler Waveform contour

A

rapid systolic upstroke
sharp systolic peak
clear spectral “window” under peak

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42
Q

supplies brain directly
lowest peripheral resistance
highest diastolic flow velocities with forward flow throughout cardiac cycle

A

ICA

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42
Q

relatively high resistance vascular bed; includes muscles of face and mouth; produces lower diastolic flow velocities; often results in a multiphasic waveform

A

ECA

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42
Q

takes on characteristics of both ICA and ECA; low resistance flow pattern with forward flow through cardiac cycle

A

CCA

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43
Q

____% of normal CCA flows through ICA

A

70

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44
Q

higher resistance flow pattern with forward flow throughout cardiac cycle
higher resistance flow pattern that reflects status of multiple vascular bed that it supplies: arm (high resistance), face (high resistance), brain (low resistance)

A

brachiocephalic artery

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45
Q

slight focal dilation in artery where baroreceptors assisting in reflex blood pressure control are located; typically involves origin and proximal segments of ICA, but dilated segment may also include distal CCA or origin of ECA

A

carotid sinus or carotid bulb

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46
Q

dictate that the flow pattern within a significant stenosis will be characterized by a high-velocity jet

A

hemodynamic principles

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47
Q

the situation where one vascular bed draws blood away or steals from another

A

steal waveform

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48
Q

flow that is beginning to show signs or reversal, not yet completely retrograde

A

latent steal

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49
Q

possess a deep flow reversal notch when flow pauses before progressing cephalad

A

hesistant steal

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50
Q

deep notch in Doppler waveform extends below baseline, with a portion of the flow being retrograde during part of the cardiac cycle

A

alternating or bidirectional

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51
Q

changing pressure gradients at origin of ipsilateral vertebral artery can alter ratio of antegrade to retrograde flow in the vertebral artery to the point when flow is entirely in retrograde direction

A

complete steal

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52
Q

characterized by low-velocity, somewhat resistive waveforms, pattern that proceeds complete occlusion of a vessel; most likely to be found in severely diseased ICA

A

“string sign” flow

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53
Q

tend to involve proximal and origin segments of ECA, associated with: focal velocity increase, postenotic turbulence, and dampened waveform distally

A

ECA stenosis

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54
Q

generate symmetrically abnormal Doppler arterial waveform contour in right and left carotids; brachial systolic pressures may also be symmetrically low

A

aortic valve or root stenosis

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55
Q

decreased pressure and waveform changes in right CCA and subclavian artery and their distal branches

A

Severe stenosis or occlusion of brachiocephalic artery

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56
Q

a severe distal ICA obstruction with continued patency of bifurcation

A

“choke” lesion

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57
Q

an unusual waveform with two prominent systolic peaks separated by a mid-systolic refraction

A

pulsus bisferiens

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58
Q

the angle between the line of the ultrasound beam and the arterial wall at site of PW Doppler sample volume

A

Doppler angle of insonation

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59
Q

obtained using an angle of insonation of 60 degrees or less

A

arterial velocity measurements

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60
Q

Carotid and vertebral systems are connect by ______ at the base of the brain.

A

circle of Willis

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61
Q

low resistance pattern; antegrade flow (toward the brain); rapid systolic acceleration; sharp peak and relatively high diastolic flow

A

vertebral artery

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62
Q

generally occur at origin of vessel from subclavian artery

A

vertebral artery stenosis

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63
Q

Normal PSV

A

30-50 cm/s

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64
Q

occurs with severe stenosis or occlusion of subclavian artery proximal to origin of vertebral artery; causes decreased pressure at origin of ipsilateral vertebral artery

A

subclavian steal

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65
Q

provocative noninvasive test that can be used to augment a subclavian steal from the latent or hesitant stages to complete stage

A

reactive hyperemia

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66
Q

produced by period of arterial occlusion; results in vasodilation and an increase in brachial systolic pressure gradient

A

tissue ischemia

67
Q

What is the secondary goal of examination of the extracranial carotid artery system by duplex ultrasound?

A

to document progression of the disease

68
Q

Which transducer is most commonly used to perform a duplex evaluation of the extracranial cerebrovascular system?

A

12-3Mhz linear array

69
Q

A patient presents to the vascular lab for a carotid-vertebral duplex examination. Upon questioning, the patient reveals a 2 week history of intermittent blindness in the right eye. What would these symptoms indicate?

A

TIA

70
Q

How should the patient’s head be positioned in order to expedite a carotid-vertebral duplex examination?

A

head rotated 45 degrees away from side being examined with a pillow under the shoulders

71
Q

What is the most common technique used to identify the vertebral artery?

A

view the CCA and angle the transducer slightly posterior

72
Q

When qualifying the appearance of plaque by ultrasound, the use of which of the following terms is discouraged owing to poor reliability?
a. homogeneous/heterogeneous
b. smooth/irregular
c. ulcerated
d. calcified

A

c

73
Q

As plaque develops and fills the carotid bulb, what change can be expected in the Doppler waveform at theis level?

A

disappearance of normal flow separation

74
Q

Which of the following will NOT result in symmetrical changes in the Doppler spectra?
a. aortive valve or root stenosis
b. brain death
c. subclavian steal
d. intra-aortic balloon pump

A

c

75
Q

In a normally hemodynamically low-resistance system or vessel, such as the internal carotid and vertebral arteries, what will a change to high-resistance pattern suggest?

A

distal stenosis or occlusion

76
Q

What is reactive hyperemia, a provocative maneuver used during the duplex examination of the extrancranial cerebrovascular, used to demonstrate?

A

a change from latent or partial to complete subclavian steal

77
Q

Which of the following is NOT “sound” advice for sonographers who wish to prevent repetitive stress injuries while scanning?
a. be ambidextrious
b. arrange bed and equipment to be close to the patient
c. remain well hydrated during the day
d. avoid doing stretching exercises

A

d

78
Q

Why do Doppler waveforms in the CCA display a contour suggestive of relatively low-resistance flow?

A

70% of its flow supplies the ICA

79
Q

What type of flow is characterized by a blunted resistive waveform that often occurs as disease progresses to near occlusion?

A

string sign flowa

80
Q

Which statement on power Doppler is FALSE?
a. it represents the amplitude of the Doppler signal instead of frequency shift
b. It depends on the angle of insonation
c. it does not give information about flow direction
d. it can detect low flow states

A

b

81
Q

A patient presents to the vascular lab with a severe distal CCA obstruction; however, the internal carotid and external carotid artery remain patent. What is this lesion typically called?

A

choke lesion

82
Q

During duplex evaluation of the internal carotid artery, peak systolic velocities are noted to be 532 cm/s and end diastolic velocities are 167 cm/s. According the University of Washington criteria, into what stenosis category would these findings fall?

A

80-99% stenosis

83
Q

For subclavian steal syndrome or phenomenon to occur, where does a severe stenosis or an occlusion need to present?

A

the left subclavian artery or brachiocephalic artery proximal to the vertebral artery origin

84
Q

Which of the follow would affect puled Doppler spectrum contour in all vessels of the extracranial cerebrovascular arterial system even when no disease is present?
a. low cardiac output
b. aortic root stenosis
c. intra-aortic balloon pump
d. all of the above

A

d

85
Q

During duplex evaluation of the carotid artery system, velocities in the external carotid artery reached 250 cm/s, and turbulence was noted just after the area of increased velocty. What do these findings suggest?

A

> 50% stenosis

86
Q

The primary goal of an examination of the extracranial cerebrovascular system by duplex ultrasound is to identify patients at risk for _____.

A

stroke

87
Q

Approximately ____ of neck bruits are related to significant stenosis of the ICA.

A

1/3

88
Q

Lesions or stenoses in the internal carotid arteries can be present without _____ symptoms.

A

neurologis

89
Q

High-grade stenoses of the internal carotid arteries, as flow restricting lesions, are rarely the primary cause of neurologic symptoms because of ______.

A

collateral flow

90
Q

Flow separation can be seen in the carotid bulb and will be represented by brief flow ____.

A

reversal

91
Q

Transient symptoms manifested as a difficulty to speak are termed as ____.

A

aphasia

92
Q

Neurologic deficits lasting between 24 and 72 hours are classified as _____.

A

RIND
(reversible ischemic neurologic deficit)

93
Q

If significant flow turbulence is noted in the proximal right common carotid, it becomes imperative to examine the _____.

A

brachiocephalic artery

94
Q

There are usually two recommended methods to distinguish the internal from the external carotid artery. In one method, one would perform _____ to demonstrate oscillations on the Doppler spectru,

A

temporal tap

95
Q

The use of a curved or phased array transducer is recommended for the examination of the distal internal carotid arteries, particulary in patients with tortuous vessels, fibromuscular dysplasia, or vessels that are _____ than usual.

A

deeperI

96
Q

In order to evaluate the subclavian artery, the transducer is placed in a(n) _______ orientation at the base of the neck

A

transverse

97
Q

The internal featuresa of plaque found in the extracranial cerebrovascular system are usually related to the _____ of the plaque

A

echogenicity

98
Q

Bleeding within a plaque underneath the fibrous cap (intraplaque hemorrhage) can cause the plaque to become ____.

A

unstable

99
Q

Dissection of the intima, particular in common carotid arteries, could be confused with artifacts from the wall of ______.

A

internal jugular veins

100
Q

______ injury is defined as any adverse patient condition that is induced inadvertently by a health care provider during a diagnostic procedure or intervention.

A

iatrogenic

101
Q

“latent”, “hesitant”, “alternating”, and “complete” are terms usually describing the stages of ______.

A

steal phenomenon

102
Q

The wavform contour distal to a significant stenosis is often referred to as a ______ pattern, characterized by damp, rounded waveform with decreased velocity and delayed acceleration

A

tardus parvus

103
Q

In the presence of significant common carotid stenosis, the ICA/CCA ratio criteria are _____.

A

not valid

104
Q

_____ Doppler is particularly helpful in detecting extremely low-flow velocities, including string sign flow.

A

power

105
Q

According to the criteria developed by the University of Washington, ,the stenosis categories below the 50% threshold are differentiated from one another by the presence or absence of flow separation, the extent of spectral ______, and the amount of plaque visualized.

A

broadening

106
Q

Symptoms of vertebrobasilar insufficiency include all of the following except:
a. ataxia
b. diplopia
c. dizziness
d. amaurosis fugax

A

d

107
Q

What is the best method for evaluating an arterial segment for stenosis?

A

sweep through with spectral Doppler

108
Q

Which of the following is a potential pitfall in performing a temporal tap maneuver?
a. visible oscillation occurs in the ECA and not in the ICA
b. performing a temporal tap in the presence of an ICA occlusion
c. oscillations may be transmitted within the ICA if the temportal artery is tapped too strongly
d. No oscillations will be generated if the temporal artery is inadequately tapped

A

a

109
Q

What is the name of the artifact caused by heavily calcific plauqe?

A

acoustic shadowing

110
Q

Neurologic defecits that occur intermittently, lasting from several minutes to a few hours, symptoms resolve within 24 hours

A

Transient Ischemic attack

111
Q

fixed or permanent neurgolic defects

A

cerebrovascular accident

112
Q

Neurologic defecits that last between 24 and 72 hours

A

reversible ischemic neurologic defecit

113
Q

Carotid artery duplex evaluation generally includes examination of bilateral:

A

CCAs
ICAs
ECAs
vertebral arteries
subclavian arteries

114
Q

Color Doppler should be used to identify:

A

areas of aliasing or mosaic flow patterns
speckling that could indicate color bruit

115
Q

Pulsed wave spectral Doppler is used to”

A

measure flow velocities
document waveform contours

116
Q

ECA spectral waveform will oscillate with _____.

A

temporal tap

117
Q

ICA typically lies _____ to ECA

A

posterior

118
Q

Plaque most often occurs at the _____.

A

CCA bifurcation

119
Q

_____ may form between plaque and lumen.

A

fibrous cap

120
Q

By ultasound plaque is usually classified as _____ vs. ______ or ______ vs. _______.

A

smooth
irregular
homogeneous
heterogeneous

121
Q

Provides the most reliable means for assessing vessel patency and classifying degree of stenosis

A

Spectral Doppler

122
Q

Doppler waveform is related to:

A

cardiac output
vessel compliance
status of distal vascular bed

123
Q

distal vascular bed:

A

ciricle of Willis

124
Q

ICA has _____ diastolic velocities and _____ peripheral resistance.

A

highest
lowest

125
Q

ECA has _____ diastolic velocities and _____ peripheral resistance.

A

lowest
highest

126
Q

slight focal dilation in the carotid artery

A

carotid bulb

127
Q

contains baroreceptors that assist in blood pressure control

A

carotid bulb

128
Q

a situation where one vascular bed draws blood away or steals from another

A

steal

129
Q

Degree of steal depends on:

A

Severity of stenosis
resistance offered by the various downstream vascular beds

130
Q

flow that is beginnings to show signs of reversal but not completely retrograde
waveform characteristics can be:
hesitant (deep flow reversal notch)
alternating or bidirectional

A

latent steal

131
Q

complete retrograde flow of vessel involved

A

complete steal

132
Q

Associated with the following findings in extracranial ICA:
decreased diastolic flow or resistive compnent
overal “blunted” appearing waveform

A

Distal ICA stenosis or occlusion

133
Q

Associated with:
focal velocity increase
poststenotic turbulence
damplened distal waveform

A

ECA stenosis

134
Q

_____ may result in retrograde ECA to supply ICA

A

Choke lesion

135
Q

Will generate symmetrically abnormal Doppler wavefor,m contouir in the bilateral carotid systems; may also cause bilateral low brachial systolic pressures

A

aorti valve or root stenosis

136
Q

Brachiocephalic stenosis will only affect the ___ carotid system

A

right

137
Q

PSV > 230 cm/s
ICA/CCA ratio >4.0

A

> 70% stenosis

138
Q

low resistance
antegrade flow throughout cardiac cycle
brisk systolic acceleration, sharp peak, and relatively high diastolic flow

A

vertebral artery flow

139
Q

Symptoms of vertebrobasilar insufficiency include all of the following except:
a. dizziness
b. ataxia
c. amaurosis fugax
d. diplopia

A

c

140
Q

What is the best method for evaluating an arterial segment for stenosis?

A

sweep through with spectral Doppler

141
Q

Which of the following is not a potential pitfall in performing a temporal tap maneuver?
a. Performing a temporal tap in the presence of an ICA occlusion
b. Visible oscillation occurs in the ECA and not in the ICA
c. Oscillations may be transmitted within the ICA if the temporal artery is tapped too strongly
d. No oscillations will be generated if the temporal artery is inadequately tapped

A

b

142
Q

What is the name of the artifact caused by heavily calcific plaque?

A

acoustic shadowing

143
Q

Which of the following is true about normal ICA flow?
a. low resistance flow with low diastolic flow component
b. high resistance flow with low diastolic flow componenet
c. high restistance flow with high diastolic flow compenent
d. low resistance flow with high diastolic flow component

A

d

144
Q

What crucial element should be documented when confirming string that sign flow is present (and the ICA is not completely occluded)?

A

presence of Doppler flow in the mid/distal ICA

145
Q

What is meant by the term “choke lesion”?

A

severe stenosis or occlusion of the CCA

146
Q

Which of the following would invalidate the ICA/CCA ratio (NASCET method)?
a. severe stenosis of the ECA
b. Severe stenosis of the ascending aorta
c. severe stenosis of the CCA
d. Severe stenosis of the contralateral ICA

A

c

147
Q

What does spectral broadening in the Doppler waveform generally represent?

A

turbulent flow

148
Q

Flow separation is:
a. only observed at a flow reducing carotid stenosis
b. a term referring to retrograde flow in the ECA, which feeds the ICA
c. observed in the CCA in patients with aortic insufficiency
d. often observed at the carotid bulb and appears as a small area of flow reversal

A

d

149
Q

The normal position of the vertebral arteries is:

A

passing through the transverse processes of the cervical vertebrae

150
Q

The characterization of an ulcerative plaque is best done with:

A

a pathologic specimen at time of surgery

151
Q

Which of the following statements about the ECA is not true?
a. it supplies a low resistance bed
b. it can demonstrate a multiphasic waveform similar to a peripheral artery
c. it demonstrates lower diastolic velocities when compared with the ICA
d. It supplies the muscles of the face and mouth

A

a

152
Q

In a patient with reversed right vertebral artery flow, the possible cause of the steal can be:

A

a stenosis in the brachiocephalic artery

153
Q
A
154
Q
A
155
Q
A
156
Q

The concensus criteria use which two values as secondary parameters for ICA disease classification?

A

The ICA end-diastolic velocity (EDV) and the ICA/CCA peak systolic velocity ratio

156
Q

The main advantage of power Doppler imaging is:

A

the ability to detect low flow startes

156
Q

Which of the following statements correctly identifies the calculation of the ICA/CCA peak systolic velocity ratio?
a. Use the highest PSV from the stenotic site for the ICA and the PSV from the normal mid to distal CCA
b. use hte highest PSV from the stenotic site for the ICA and the PSV from the proximal CCA
c. Use the highest PSV from the ICA and the highest PSV from the CCA
d. Use only the proximal ICA PSV and the PSV from the normal mid to distal CCA

A

a

157
Q

Gold standard techniques used to validate carotid ultrasound criteria include all of the following except:
a. CTA
b. MRA
c. Contrast arteriography
d. MRI

A

d

158
Q
A
159
Q
A
160
Q
A
161
Q
A
161
Q

The transducer maneuver used to adjust vessel insonation to help create an angle of 60 degrees or less is called:

A

toe-heel maneuver

161
Q

Cardiac assist devices used in patients with heart failure can have what affect on carotid artery signals?

A

the contour is affected such that the pattern of arterial flow is unrecognizable

162
Q
A
163
Q
A

Vascular (33 decks)

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