Extra Cranial

Question 1

Arterial palpation

Answer 1

Common carotid : bifurcation 
Superficial temporal 
Subclavian: above/below clavicle
Axillary
Brachial: antecubital fossa

Question 2

Bruit

Answer 2

Abnormal sound heard on auscultation caused by turbulent flow.

Bruit that’s no longer heard could mean progressed to >90% diameter reduction

Question 3

Hemorrhagic Stroke

Answer 3

Bleeding in brain. Blood vessel bursts in brain causing damage to brain tissue. Most common cause: HTN

Question 4

Ischemic Stroke

MC type. 3rd leading cause of death.

80% thrombo embolia with carotid MC source.

Answer 4

Interruption of blood supply to brain causing decrease in oxygen to brain. MC cause: blood clot/emboli. MC factor: atherosclerosis.

Question 5

Lacunar Stroke

Answer 5

Obstruction of small perforating arteries that supply deep areas of brain. MC: elderly diabetic or poorly controlled HTN

Question 6

Transient Ischemic Attack TIA

Answer 6

Few mins to no more than 24 hours.

Symptoms: unilateral and contralateral
•amaurosis fugax (monocular blindness-black shade coming into eye) (ipsilateral)
•dysphasia/aphasia: impaired language 
•contralateral hemiparesis
•abnormal behavior 

MC: emboli that is non flow limiting stenosis

Question 7

Reversible Ischemic Neurologic Defect RIND

Answer 7

Symptoms last more than 24 hours. Patient reverts back to normal.

Symptoms: unilateral and contralateral except for eye (ipsilateral)
•amaurosis fugax (ipsilateral)
•dysphagia/aphasia: impaired language 
•contralateral hemiparesis
•abnormal behavior

Question 8

Vertebrobasilar insufficiency

Answer 8

Flow obstruction in posterior circulation.

Temporary

Symptoms usually bilateral. 
•ataxia: inability to coordinate muscle activity
•drop attacks
•vertigo: dizzy
•bilateral visual disturbances 
•dyplopia: double vision

Question 9

Cerebrovascular Accident CVA

Answer 9

Complete Stroke with permanent and lasting neurological deficit.

Symptoms:
•dysphasia/aphasia: lose ability to understand speech. Impaired language.
•hemiparesis
•death
•miscellaneous neurological defects: facial droop, loss of vision

Risk:
Diabetes mellitus 
HTN
Smoking
Hyperlipidemia

Question 10

Atherosclerosis

Answer 10

A form of arteriosclerosis (when arteries become thick and stiff, restricting blood flow)

Atherosclerosis: buildup of fat, cholesterol, substances in artery walls. Disease or intima,íntima proliferation (hyperplasia), deposition of fatty substances and luminal reduction

Risk: diabetes, HTN, hyperlipidemia, smoking, age, gender, family hx, hypercoagulopathy

Question 11

Types of atherosclerotic plaque

Answer 11

Fatty streak: homogeneous thick layer of lipid material on intimas layer.

Fibrous (soft) plaque: homogeneous accumulation of lipids, collagen, and elastic fibers.

Complicated lesion: heterogeneous, bright echoes with shadowing fibrous plaque that include collagen, calcium, and cellular debris.

Ulcerative: deterioration of smooth fibrous plaque. May shed debri that embolizes.

Question 12

Abnormal intimal thickening = _____ mm

Answer 12

0.9mm or more

Question 13

Hemodynamically significant stenosis :
area of lumen is reduce 75%
Or a 50% diameter reduction

Answer 13

Diameter reduction:
•True diameter-residual diameter=plaque diameter
•Plaque diameter / true diameter *100= % diameter stenosis.

Area reduction:
•residual/true = % residual open
•100% - %residual = % of stenosis

Question 14

Stenosis velocities and ratios

Answer 14

Normal : <125 cm/s , <2.0 ratio
<50% : <125 cm/s , <2.0 
50-69% : 125-230, 2.0-4.0 ratio
> or = 70% : >230cm/s , > 4.0 ratio
Near occlusion 
Total occlusion, no flow

Question 15

CCA

Answer 15

Low resistant, higher resistant near prox.

Abnormal: no diastolic flow = ICA occlusion further up.

Question 16

ECA

Answer 16

High resistant
Branches
Important collateral pathway when there’s disease.

Abnormal ECA: no threshold values

Question 17

Innominate artery

Answer 17

Gives rise to RT CCA and RT subclavian
Feeds arm, and cerebral circulation

Abnormal: when there’s a stenosis in Innominate, you’ll see tardus parvus in RT CCA

Question 18

Patients with poor cardiac output will show _____ PSV in carotid exam bilaterally

Answer 18

Low PSV

Question 19

Bicephorous waveform. Double peaks. Seen in patients with

Answer 19

Severe Aortic regurgitation.

Sharp upstroke. 2 peaks separated by a diacrotic notch. 2nd peak equal or taller than first.

Question 20

If see tardus parvus in bilateral ICA, would be indicative of ______

Answer 20

Aortic valve stenosis.

Tardus Parvus: Prolonged acceleration, blunted amplitude, rounded waveform.

Question 21

ICA occlusion

Answer 21

If ICA is occluded,

ECA collateral can be mistake for ICA. Becomes low resistant. Internalization of ECA.

May see increase flow in contralateral ICA = compensatory flow

Externalized (High resistant flow patterns) of ipsilateral CCA

Not operative

Question 22

Near occlusion of ICA

Answer 22

Endarterectomy done when stenosis.
For string lesions or diffuse narrowing of ICA it’s not possible due to no focal stenosis to be removed. May lígate ICA to decrease source of emboli

Question 23

If CCA occluded

Answer 23

Branches of vertebral system supply ECA and

ECA will show retrograde flow to feed ICA

Question 24

Carotid artery dissection

Answer 24

Blood enters artery wall, separating wall layer, creating a false lumen

Echogenic flap, blood in false lumen may thrombos

Causes: trauma MC, connective tissue disorder Marfan’s syndrome or Ehler’s-Danlos

In Carotid: MC cause is atherosclerosis. Can extend to ICA

(MC dissection occurs in ascending aortic arch. )

Question 25

ICA dissection

Answer 25

Usually begins at base of skill. Trauma or spontaneous. Strenuous exercise. Rapid neck motion. Risk: HTN.

Symptoms: headache, neck and face pain. Hemispheric ischemic symptoms.

Smooth tapering ICA without plaque.

Question 26

Carotid pseudoaneurysm (false aneurism)

Answer 26

Puncture in arterial wall
Violent trauma. Example : IJV cath or during arteriography.

Stent repairs.

To and fro pattern in neck of pseudo

Question 27

Carotid arteriovenous fistula

Answer 27

Communication between artery and vein.

MC trauma.

Turbulence, visible color bruit (speckles), high velocity jet at connection site.

Question 28

Fibromuscular dysplasia

Answer 28

Non atherosclerotic lesión caused by hyperplasia usually in tunica media.

Usually distally. MC at renal artery. And ICA.
Usually women. 3:1. Age 25-50

Asymptotic, cervical bruit.

String of pearl appearance, multiple arterial stenosis.

If in ICA, usually >1cm passed bifurcation.

Question 29

Carotid body tumors aka chemodectoma or paragangliomas

Answer 29

Highly vascular. Usually benign. Lies in adventitia “crotch” of the carotid bifurcation.
Usually fed by ECA

Common in people who live in high altitudes.

Palpable neck mass with neck pain.

Tumor may surround ECA or ICA causing stenosis and complicating surgical excision.

Question 30

Neointimal hyperplasia

Answer 30

Intimal thickening from hyperplasia of smooth muscle cells. Usually due to vascular injury.

Example: 2 years after endarterectomy

Question 31

Takayasu Arteritis

Answer 31

The pulse less disease

Inflammation of walls in the largest arteries in body. Aorta and branches.

MC: women

Diagnosed by angiography; shows tubular narrowing of large arteries.

Loss of pulse in arms and legs

Question 32

Temporal arteritis aka Giant Cell Arteritis

Answer 32

Inflammation of distal segment of the superficial temporal artery or its frontal and or parietal branches.

Narrowed parts of vessel and anechoic halo around vessel lumen secondary to edema.

Headaches, tender palpated temporal artery

Steroid therapy treatment: prednisone