Pathology Pt 1 Flashcards
1
Q
According to the Bernoulli principle, the velocity increases at an area of stenosis. What happens to the pressure at the site of stenosis?
A. remains constant
B. decreases
C. increases
D. it increases exponentially
A
B
FeedBack:The pressure proximal to the stenosis is very high. The pressure at the stenosis is very low causing an increased pressure gradient between the two sites. The higher the pressure gradient, the higher the velocity.
2
Q
Which intracranial artery is most commonly associated with stroke?
A. basilar
B. ACA
C. MCA
D. PCA
A
C
FeedBack:The MCA is a continuation of the distal ICA. Embolism from an ICA stenosis will most likely lodge in the MCA unless it is small enough to pass through into the circle of willis.
3
Q
Which of the following scenarios demonstrates the highest risk for TIA?
A. Buerger disease
B. 40% ICA stenosis with mild, irregular soft atheroma
C. 60% ICA stenosis with moderate, smooth calcific atheroma
D. chronic ICA occlusion
A
B
FeedBack:Stenosis of the internal carotid artery carries the highest risk of TIA. Soft plaque has a much higher risk of embolization than the “fixed” calcific atherosclerosis.
4
Q
You are performing a TCD exam to assess collateral flow with a right ICA occlusion. You identify flow moving away from the transducer at 90cm/s with decreased pulsatility in the right ophthalmic artery. The left ophthalmic artery demonstrates flow moving toward the transducer with a velocity of 45cm/s. What is indicated by these findings?
A. Normal flow parameters, no collateralization present
B. ECA to ICA collateralization
C. Posterior to anterior collateralization
D. Cross over collateralization
A
B
FeedBack:The superficial temporal artery and the inferior maxillary artery are branches of the ECA that communicate with branches of the ophthalmic artery. Flow moves from the ECA to these branches and refills the ophthalmic artery to send flow back into the areas affected by the ipsilateral ICA occlusion.
5
Q
The image demonstrates a complication that is most common with what type of carcinoma?
Image shows echogenic area in IVC
A. Hepatic
B. Renal
C. Splenic
D. Pancreatic
A
B
FeedBack:Renal carcinoma has been shown to infiltrate the renal vein and IVC causing mass and thrombus formation within. It is the most common type of tumor with IVC/renal vein invasion.
6
Q
All of the following are potential acute complications that can occur with a recent liver transplant, except:
A. hepatic vein thrombosis
B. biloma
C. portal vein thrombosis
D. hepatic artery atherosclerosis
A
D
FeedBack:Atherosclerosis formation is a chronic process. Thrombosis and biloma formation are acute complications that can be seen with a recent liver transplant.
7
Q
A patient presents for a carotid ultrasound. The chart states a history of 2 recent episodes of amaurosis fugax. Which statement best describes amaurosis fugax?
A. Monocular blindness
B. Bilateral blindness for more than 24hrs
C. Spots flashing in front of eyes
D. Dizziness upon standing
A
A
FeedBack:It occurs when a piece of plaque in the carotid artery breaks off and travels to the retinal artery in the eye. In people with amaurosis fugax, vision loss continues as long as the blood supply to the retinal artery is blocked. This usually only lasts seconds but may last several minutes. Some patients describe the loss of vision as a black shade coming down over their eye.
8
Q
The Doppler tracing of the flow in a vessel just distal to a stenosis will demonstrate _____________ than at the stenosis.
A. greater bandwidth
B. greater resistance
C. more laminar flow
D. greater Doppler shift
A
A
FeedBack:Turbulence will cause a large range of different velocities (frequency shifts). The increased bandwidth is displayed as spectral broadening and irregular waveform contour(post stenotic turbulence).
9
Q
All of the following correctly describe Hereditary Hemorrhagic Telangiectasia that affects the liver, except:
A. Can cause mesenteric angina from steal phenomenon
B. Autosomal recessive disorder
C. Can be associated with an portovenous AVM in the liver
D. Can be associated with an arteriovenous AVM in the liver
A
B
FeedBack:Hereditary Hemorrhagic Telangiectasia, AKA Osler-Weber-Rendu syndrome, is an autosomal dominant disorder that affects the vasculature of multiple organs. It is characterized by multiple arteriovenous malformations (AVMs). Most commonly the AVMs are superficially located in the skin, but can also occur in pulmonary, cerebral, GI tract, and liver vasculature. Contrast echocardiography can be used to diagnose a suspected pulmonary AVM. Ultrasound is most helpful in evaluating liver AVMs. The malformations can be arteriovenous or portovenous. Ultrasound evaluation can demonstrate signs of portal HTN due to increased portal flow and increased resistance in the hepatic arterial flow with abnormal arterial connections. The disorder can cause mesenteric angina from the steal phenomenon .
10
Q
Budd Chiari syndrome refers to acute or chronic obstruction of which vessel(s)?
A. Splenic veins
B. Hepatic veins
C. Splenic artery
D. Hepatic artery
A
B
FeedBack:Obstruction of hepatic veins by thrombus or tumor is referred to as Budd Chiari syndrome. It can lead to symptoms and complications such as hepatic congestion, hepatomegaly, ascites, RUQ pain and jaundice.
11
Q
If the P1 segment of the PCA is occluded on the left side, how will flow reach the P2 segment of the PCA?
A. flow reversal within the right posterior communicator artery
B. cross over flow through the branches of the MCA
C. flow reversal within the left posterior communicator artery
D. flow reversal in the basilar artery
A
C
FeedBack:Flow in the left posterior communicator artery will travel posterior from the left distal ICA to reach the P2 segment.
12
Q
If there is an occlusion at the proximal ICA, what will happen to the flow in the CCA?
A. Damped with increased resistance/decreased diastolic flow
B. Turbulent with decreased resistance/increased diastolic flow
C. Damped with unaffected resistance
D. No effect on CCA flow until bulb area
A
A
FeedBack:The ECA normally demonstrates high resistance systolic flow with minimal diastolic flow. The ICA usually demonstrates low resistance systolic flow with increased diastolic flow. The CCA normally demonstrates a combined flow pattern from both of the branches with resistance and diastolic flow at levels between the ECA and the ICA. If the ICA is occluded, the CCA will demonstrate a flow pattern very similar to the ECA because it is now the only CCA branch and resistance to flow is increased.
13
Q
Which of the following causes an increase in the resistive index(RI) of the distal common carotid artery?
A. proximal ICA stenosis
B. aortic valve insufficiency
C. Valsalva maneuver
D. proximal CCA stenosis
A
A
FeedBack:An occlusion of the ICA will lead to increased resistance to the flow in the ipsilateral common carotid artery.
14
Q
According to the Bernoulli Principle, where will you find the lowest pressure in a vessel with stenosis?
A. at the site of stenosis
B. proximal to the stenosis
C. distal to the stenosis
D. in the collateral vessels
A
A
FeedBack:Pressure is lowest at the stenotic site which causes an increased pressure gradient from proximal to the stenosis to the stenosis site. This increased gradient leads to increased velocity of flow across the stenotic site.
15
Q
Which of the following describes the sonographic appearance of an acute occlusive DVT?
A. Hyperechoic material adhered to vessel wall causing partial non-compressibility
B. Anechoic/Hypoechoic material causing the vein to appear engorged with complete non-compressibility
C. Area of increased echogenicity within the venous lumen causing decreased augmentation response
D. Homogenous, hyperechoic material engorges the vein with no color fill in the vessel.
A
B
FeedBack:Answers A and C refer to the appearance of chronic/partial DVT. As the thrombus ages, it becomes more fibrous and dense which leads to an increase in echogenicity. Acute DVT usually leads to total occlusion of the vessel and there will be no flow within the affected vessel. Augmentation is usually not recommended for cases of acute DVT.
16
Q
Which of the following vessels can act as a collateral vessel to redistribute flow from one side of the brain to the other side?
A. posterior communicator artery only
B. anterior communicator and basilar artery
C. anterior communicating artery only
D. middle cerebral artery only
A
B
FeedBack:The anterior communicating arteries can allow flow to move from one ACA into the other. If the left ICA is occluded, flow from the right ICA enters the brain and travels to the right ACA. Flow then moves through the communicator to fill the left ACA in a retrograde fashion.
The cerebellum is supplied by blood from branches of the vertebral arteries and basilar artery. If the left vertebral is occluded proximally, flow moves cephalad toward the brain in the right vertebral artery and then some of this flow is redirected caudally into the left vertebral (retrograde filling).
17
Q
You identify flow moving toward the transducer in the left ophthalmic artery and flow moving away from the transducer in the right ophthalmic artery. Which of the following explains these findings?
A. critical stenosis in the distal left ICA
B. critical stenosis in the right ACA
C. critical stenosis in the left ACA
D. critical stenosis in the distal right ICA
A
D
FeedBack:Flow in the ophthalmic arteries is normally evaluated in the orbital window and demonstrates flow toward the transducer. If the flow is reversed in one of the vessels, this indicates a critical stenosis in the ipsilateral ICA with ECA to ICA collateral flow.
18
Q
Which statement best describes the findings on the image?
image looks like irregular bordered intimal thickening
A. Neointimal hyperplasia has developed around a stent.
B. There is soft atheroma formation within the CCA.
C. There is heterogeneous, complex atheroma formation within the CCA.
D. The image demonstrates and area of recanalization through a thrombus.
A
B
FeedBack:The image demonstrates homogeneous, soft atheroma formation within the CCA lumen.
19
Q
A proximal femoral artery stenosis will cause the __________________ in the mid femoral artery.
A. acceleration time to decrease
B. velocity to increase
C. acceleration time to increase
D. Reynold’s number to decrease
A
C
FeedBack:Acceleration time refers to the time from the start of systole to peak systole. High resistance vessels have short acceleration times. Low resistance vessels and areas distal to a stenosis will demonstrate longer acceleration times.
20
Q
All of the following are potential causes of a false negative diagnosis of ICA stenosis, except:
A. decreased cardiac output
B. tortuosity
C. improper Doppler angle
D. CHF
A
B
FeedBack:A curved vessel will cause increased velocities at the “kinked” location(s). This can cause a false positive diagnosis of stenosis.
21
Q
When evaluating the Doppler waveform at a focal stenosis in the proximal ICA, which of the following Doppler characteristics will be demonstrated?
A. increased peak systolic velocity, increased diastolic flow reversal
B. increased peak systolic velocity, decreased end diastolic velocity
C. decreased peak systolic velocity, increased end diastolic velocity
D. increased peak systolic velocity, increased end diastolic velocity
A
D
FeedBack:The Doppler waveform at a focal ICA stenosis will demonstrate increased peak systolic velocity and increased end diastolic velocity.
22
Q
Broca’s aphasia can be defined as:
A. Inability to understand speech, speak, or follow directions
B. Inability to swallow solid food
C. Inability to swallow liquids
D. Inability to speak but can understand and follow directions
A
D
FeedBack:Broca’s aphasia (AKA expressive aphasia) can be defined as the inability to speak but can understand and follow directions.
23
Q
Which of the following statements is true regarding the images displayed?
image of RT CCA
gray scale - looks like thick intimal thickening
spectral- spectral broadening, PSV - 2.0
A. There is focal atherosclerosis formation within the distal CCA.
B. The increased PSV in the CCA is due to a single site of stenosis causing increased velocity and turbulence.
C. The increase in PSV in the CCA is due to the multiple adjacent lesions causing increased resistance.
D. The Doppler tracing indicates laminar flow.
A
C
FeedBack:Note the diffuse atheroma formation along the length of the CCA which causes a combined effect on the flow velocity within the vessel.
24
Q
While performing a TCD exam using the left transtemporal window, you identify flow moving away from the transducer with a mean flow velocity of 95cm/s in the A1 segment of the left anterior cerebral artery. From the right temporal window, the A1 segment of the right anterior cerebral artery demonstrates flow moving toward the transducer with a mean flow velocity of 30cm/s. Which of the following explains these findings?
A. occlusion of the right A1 segment at its origin from the ICA
B. normal flow directions and velocities are demonstrated
C. occlusion of the left A1 segment at its origin from the ICA
D. Occlusion of the anterior communicator artery
A
A
FeedBack:A high grade stenosis or occlusion of the right distal ICA or right proximal ACA will produce these findings. From the transtemporal window, normal flow in both of the ACAs should be moving away from the probe and toward the anterior cranium. If the right proximal ACA is obstructed, little to no flow will move into the A1 segment. The flow in the left A1 segment will increase in velocity to pass through the anterior communicator artery to enter the right A1 segment. This will lead to flow reversal in the right A1 segment as flow moves from the anterior brain to the mid brain (toward the probe at the temporal window).
25
All of the following are related to acute DVT, except:
A. Calf pain
B. Wet ulceration
C. Swelling
D. Engorged, non-compressible vein
B
FeedBack:Ulcerations take time to form. They are a sign of chronic venous disease.
26
The external carotid artery normally demonstrates a velocity below:
A. 100cm/s
B. 80cm/s
C. 150cm/s
D. 230cm/s
C
FeedBack:The external carotid artery normally demonstrates a velocity below 150 cm/s
27
Which of the following is a cause for deep venous HTN?
A. Klippel Trenaunay Webber Syndrome
B. CHF
C. Diffuse atherosclerotic disease
D. aortic coarctation
B
FeedBack:Venous HTN is described as increased venous volume that causes fluid to leak into interstitial spaces between tissues. Related to thrombus formation, venous insufficiency, CHF, pregnancy
28
Which of the following visual disturbances is described when half of the field of view is disrupted in the eye?
A. ectopia
B. myopia
C. homonymous hemianopia
D. diplopia
C
FeedBack:This visual disturbance can be unilateral or bilateral and is commonly caused by ischemia in the occipital lobe of the brain. Medial or lateral half of the field of view in the eye is "absent" while the other half appears normal.
29
Which of the following statements is true regarding the aorta?
A. The most common location for an aortic dissection is at the iliac bifurcation.
B. Rupture is the most common complication of an aortic aneurysm.
C. Suprarenal AAAs normally do not affect the arterial flow to the kidneys.
D. The majority of the aortic branches that lead to abdominal organs are lateral branches.
B
FeedBack:The most common location for an aortic dissection is in the thoracic segment. The majority of the aortic branches that lead to abdominal organs are anterior branches. Infrarenal AAAs normally do not affect the arterial flow to the kidneys.
30
A peak systolic velocity of 100 cm/s is an indication of ___________ in the ICA.
A. normal flow
B. mild stenosis
C. moderate stenosis
D. severe stenosis
A
FeedBack:The peak systolic flow velocity in the ICA is normal when it is less than 125cm/s.
31
Which of the following is a characteristic of the Doppler waveform obtained at the site of stenosis in an ICA with >70% stenosis?
A. increased diastolic flow
B. blunted waveform
C. spectral window
D. decreased acceleration time
A
FeedBack:As stenosis increases, peak systolic and end diastolic velocities increase. Acceleration time increases as stenosis increases. As the vessel nears 99% stenosis, systolic and diastolic flow may be significantly reduced. Occlusion will lead to increased resistance in the proximal vessel.
32
Which of the following indicates a significant SMA stenosis?
A. dilated inferior mesenteric artery that is easily visualized sonographically
B. PSV >200cm/s
C. mesenteric - aortic ratio > 2.5
D. pain in the abdomen when hungry that is relieved by eating/digestion
A
FeedBack:The IMA is usually very tough to find in most patients with ultrasound. If the artery is visible and easily evaluated, it usually means it is dilated due to compensatory flow related to an SMA stenosis. A PSV greater than 2.75cm/s indicates significant stenosis. If the mesenteric - aortic ratio exceeds 3.0, a significant stenosis is present.
33
In the circle of Willis, if a difference ____________ is present between the velocities taken in the same vessel on both sides, this can indicate intracerebral disease.
A. >20%
B. >30%
C. >40%
D. >50%
B
FeedBack:Blood flow velocities in the vessels of the circle of Willis should be similar between the vessels on the left and right sides. A difference >30% between the velocities taken in the same vessel on both sides can indicate intracerebral disease is presen
34
All of the following are potential acute complications of a liver transplant, except:
A. cirrhosis
B. portal vein stenosis
C. portal thrombosis
D. hepatic artery thrombosis
A
FeedBack:Cirrhosis is a chronic liver disease. Thrombosis and extrinsic vessel narrowing/compression are acute complications that can occur in a liver transplant.
35
Which vessel provides collateral flow from the ECA to the ICA on the same side of the body?
A. superficial temporal artery to the ophthalmic artery
B. lingual artery to the MCA
C. posterior communicator to the basilar artery
D. superior thyroidal artery to the ACA
A
FeedBack:Branches of the superficial temporal artery meet with branches of the supraorbital artery. Retrograde flow in the supraorbital artery will enter the ophthalmic artery, reversed flow will be identified in the ophthalmic artery. Flow will be moving back toward the ICA instead of outward toward the eye.
36
Which statement best describes the Doppler tracing from a bypass graft in the lower extremity?
spectral image- spectral broadening, Triphasic, PSV - 300
A. There is normal velocity flow with mild spectral broadening present which indicates no significant disease is present.
B. The waveform is normal velocity and appearance for the lower extremity graft segment being evaluated.
C. There is increased velocity and spectral broadening present which indicates significant stenosis is present.
D. There is increased velocity and post stenotic turbulence present which indicates significant stenosis is present.
C
FeedBack:The velocity appears to be approximately 300cm/s which is abnormal. The absence of the spectral window indicates spectral broadening.
37
Which of the following is the most common cause of venous stasis ulcer formation on the distal medial calf?
A. insufficiency in the distal thigh perforators and the great saphenous vein
B. insufficiency in the posterior tibial perforators and the posterior arch vein
C. insufficiency in the paratibial perforators and the posterior arch vein
D. insufficiency in the proximal thigh perforators and the great saphenous vein
B
FeedBack:Insufficiency in the posterior tibial perforators and the posterior arch vein most commonly leads to venous stasis ulcer formation on the distal medial calf.
38
Nutcracker syndrome is defined as:
A. abnormal compression of the celiac axis with respiration
B. entrapment of the popliteal artery seen most commonly in runners
C. entrapment of the subclavian artery by structures in the shoulder/neck
D. abnormal compression of the left renal vein by the SMA and aorta
D
FeedBack:Nutcracker syndrome is defined as abnormal compression of the left renal vein by the SMA and aorta. It can lead to renal vein congestion and thrombosis.
39
Which of the following is not a common risk factor for varicose vein formation?
A. post-phlebitic syndrome
B. pregnancy
C. smoking
D. standing for long periods daily
C
FeedBack:Smoking is a risk factor for atherosclerotic disease.
40
Which of the following is true regarding scrotal varicoceles?
A. usually occurs on left side
B. strong association with history of cryptorchidism
C. veins will reduce in size with the valsalva maneuver
D. usually occurs bilaterally
A
FeedBack:Varicoceles usually form on the left side of the scrotal sac due to the course of the left gonadal vein through the abdomen and the increased risk of compression.
41
Which of the following describes abnormal lower extremity venous flow response to distal augmentation?
A. Augmentation causes increased flow toward heart followed by flow reversal >0.5sec toward the feet
B. Augmentation causes increased flow toward feet followed by at least 3 seconds of flow reversal toward the feet
C. Augmentation causes increased flow toward feet followed by flow reversal > 0.5 sec toward the heart
D. Augmentation causes increased flow toward heart followed by flow normalization
A
FeedBack:<0.5 sec flow reversal with distal augmentation is considered within normal limits. Reflux is diagnosed when flow reversal exceeds 0.5sec. >3 sec flow reversal is considered severe venous reflux. The best answer is Augmentation causes increased flow toward heart followed by flow reversal >0.5sec toward the feet.
42
The PW Doppler tracing was obtained from the CCA. Which statement below is true regarding the image?
Image- Triphasic CCA, PSV 120
A. Normal high resistance, triphasic flow is demonstrated
B. Abnormal high resistance flow due to increased flow in Vertebral supply
C. Abnormal high resistance flow due to ICA occlusion
D. Abnormal high resistance flow due to proximal stenosis
C
FeedBack:Note the flow reversal in diastole with no antegrade flow during the full diastolic portion of the cycle. This indicates significant resistance distal to the area evaluated. An occluded ICA can lead to the increase in resistance in the CCA which causes the waveform type displayed on the image.
43
What is the most common cause of upper extremity DVT in the normal ambulatory patient population?
A. radiation therapy treatments to the chest
B. Paget - Schroetter Syndrome
C. shoulder surgery
D. indwelling catheters
B
FeedBack:Paget - Schroetter Syndrome AKA spontaneous effort thrombosis; Most common cause of axillary/subclavian DVT in the ambulatory patient population; Related to the presence of a cervical rib and thoracic outlet syndrome; Higher incidence in the dominant arm
Indwelling catheters are a common cause of upper extremity thrombosis in patients that are ill and require intravenous medication/treatment.
44
All of the following cause an increased risk of pulmonary embolism, except:
A. common femoral vein thrombosis
B. hepatic vein thrombosis
C. renal vein thrombosis
D. portal vein thrombosis
D
FeedBack:A clot in the systemic venous system can break loose and travel to the lungs. The portal system does not directly communicate with the systemic veins so a clot in the portal vein cannot lead to pulmonary embolism.
45
Erratically swirling blood just distal to an arterial stenosis refers to:
A. eddy currents or Reynold's sign
B. Reynold's sign
C. vortices or eddy currents
D. pseudoaneurysm
C
FeedBack:Vortices or eddy currents are seen just distal to a stenosis and caused increased spectral broadening.
46
If an acute left ICA occlusion is present, which of the following statements is true?
A. The right MCA flow will be decreased or absent with flow reversal in the right internal carotid siphon.
B. The right MCA will demonstrate decreased or absent flow.
C. The left ophthalmic artery will demonstrate decreased or absent flow
D. The right ophthalmic artery will demonstrate decreased or absent flow
C
FeedBack:The ICA supplies the ipsilateral MCA and ophthalmic artery with blood. If the ICA is occluded the flow in these vessels will be absent unless collateral vessels present which would lead to minimal flow in the vessels.
47
All of the following are symptoms related to ICA/MCA disease, except:
A. Unilateral visual disturbances
B. Receptive aphasia
C. Expressive aphasia
D. Dysphagia
D
FeedBack:Dysphagia refers to difficulty swallowing which is controlled by the brain stem. The vertebrobasilar system supplies the brain stem with blood.
48
Which of the following is a characteristic of an ICA waveform with 50-69% stenosis?
A. clear spectral window
B. decreased diastolic flow with EDV less than 20cm/s
C. diastolic flow reversal
D. increased peak systolic and end diastolic velocity
D
FeedBack:Stenosis in the ICA leads to increased systolic and diastolic flow velocities. Spectral broadening occurs with stenosis. Diastolic flow reversal in the ICA is identified with an occlusion distal to the Doppler sample.
49
Which vessel can provide a pathway for collateral flow from the vertebral system to the MCA on the same side of the body?
A. anterior cerebral artery
B. basilar artery
C. posterior communicators
D. basilar artery and anterior cerebral artery
C
FeedBack:The posterior communicating arteries can provide an avenue for collateral flow from the carotid system to the vertebral system on the same side of the body. If the left ICA is occluded, flow can be redirected to fill the left MCA. Flow in the left vertebral enters the PCA and then the PCoA to provide flow into the left MCA. It is important to note that the flow entering the MCA from the communicating artery will move in the normal direction (toward the transducer) using the temporal window.
50
The Doppler evaluation displays a waveform from the hepatic artery and the portal vein. Which of the following statements is correct?
Image- hepatic artery above baseline and MPV below baseline
A. The tracing is abnormal because vessels should both display hepatopetal flow
B. The tracing is abnormal because vessels should both display hepatofugal flow
C. The tracing is abnormal because baseline is inverted incorrectly
D. The tracing is normal because the flow is in opposing directions
A
FeedBack:The hepatic artery and the portal vein both carry blood into the liver (hepatopetal). The attached image demonstrates flow reversal in the portal vein which is a common sign of portal HTN.
51
A critical ICA stenosis will have what effect on the ipsilateral MCA flow?
A. increased systolic flow
B. no effect
C. increased diastolic flow
D. decreased diastolic flow
D
FeedBack:A waveform distal to a critical stenosis will demonstrate a blunted monophasic waveform with minimal or absent diastolic flow.
52
When using the suboccipital window for TCD evaluation with left lateral angulation, you detect low resistance flow moving toward the transducer with a mean flow velocity of 40cm/s at a depth of 60mm. Which of the following describes these findings?
A. normal left vertebral flow
B. normal left vertebral velocity with abnormal flow direction most likely related to a left subclavian steal
C. normal right vertebral flow
D. abnormal left vertebral velocity and flow direction most likely related to a left subclavian steal
B
FeedBack:The flow in the left vertebral is reversed but normal in velocity. A blockage in the proximal left subclavian artery can cause left vertebral flow reversal as the distal left subclavian "steals" blood from the cerebral vessels.
53
Which of the following will decrease with acute renal allograft rejection?
A. kidney size
B. resistive index from the arcuate arteries
C. echogenicity of the renal cortex
D. diastolic flow in the segmental arteries
D
FeedBack:Acute renal rejection will result in an enlarged kidney with increased echogenicity of the renal cortex. Doppler evaluation will demonstrate increased resistance in the parenchymal arteries and increased resistive index. This will decrease the amount of diastolic flow in the cortical arteries.
54
All of the following factors listed below are part of Virchow's triad of symptoms, except:
A. Blood stasis
B. Recent fall
C. Swelling
D. Polycythemia vera
C
FeedBack:Virchow's Triad:
1. Blood Stasis
2. Trauma
3. Hypercoagulability. Polycythemia vera refers to abnormally thickened blood.
Swelling can be caused by numerous vascular and non-vascular disorders. It is not one of the three risk factors listed in Virchow's Triad.
55
What effect will the findings on the image have on the Doppler tracings obtained in the iliac veins?
Image- echogenic area in IVC
A. Both iliac veins will demonstrate continuous flow
B. Both iliac veins will demonstrate pulsatile flow
C. Both iliac veins will demonstrate phasic flow
D. Both iliac veins will demonstrate normal flow patterns due to the extensive venous network in the abdomen that allows for multiple collateral pathways
A
FeedBack:Renal carcinoma has been shown to infiltrate the renal vein and IVC causing mass and thrombus formation within. It is the most common type of tumor with IVC/renal vein invasion. Obstruction of the IVC will cause flow in the iliacs to become continuous. Continuous venous flow can indicate a proximal obstruction.
56
All of the following describe vascular compression syndromes, except:
A. Hypothenar hammer syndrome
B. Thoracic outlet syndrome
C. PHACE syndrome
D. Eagle syndrome
C
FeedBack:PHACE syndrome involves congenital malformations of arterial vasculature. Eagle syndrome involves compression of the carotid artery. TOS involves compression of the vessels in the thoracic outlet. Hypothenar hammer syndrome involves compression of the ulnar artery.
57
The flow demonstrated below the baseline is:
image- flow below baseline accompanies spectral broadening above baseline
A. caused by incoming collateral flow due to the significant stenosis.
B. caused by turbulent flow at the site of the stenosis.
C. noise caused by patient respiration.
D. an example of cross talk artifact.
B
FeedBack:Eddy currents or vortices of swirling flow are seen just distal to a stenosis. These swirling currents of blood can be demonstrated as areas of antegrade and retrograde flow occurring simultaneously on the Doppler tracing.
58
While scanning through the suboccipital window with midline angulation, the mean flow velocity increases from 55cm/s to 145cm/s at 105mm in depth. What do these findings mean?
A. Normal velocity for the posterior cerebral artery
B. Significant stenosis is present in the MCA
C. Significant stenosis is present in the basilar artery
D. Normal velocity changes for the tortuous carotid siphon
C
FeedBack:The mean velocity demonstrates a significant increase at a depth of 105mm which is consistent with stenosis in the basilar artery.
59
Which of the following can lead to systolic flow reversal in the hepatic veins?
A. portal HTN
B. Budd Chiari Syndrome
C. significant tricuspid regurgitation
D. IVC thrombus at the level of the renal veins
C
FeedBack:Tricuspid regurgitation is blood flow that falls back into the right atrium. It can cause the right atrium to dilate and the chamber pressure to increase. If the pressure in the RA increases, inflow from the IVC (and hepatic veins) will be disrupted and flow reversal in systole can occur.
60
Median arcuate ligament syndrome involves compression of which vessel during respiration?
A. main portal vein
B. superior mesenteric artery
C. celiac axis
D. inferior mesenteric artery
C
FeedBack:The median arcuate ligament connects the right and left crura of the diaphragm across the anterior proximal abdominal aorta. The celiac axis origin is very close to the diaphragm and in some patients the median arcuate ligament crosses anterior to the celiac origin. Median arcuate ligament syndrome is caused by the ligament compressing the celiac axis with respiration. The aorta and branches move superiorly upon expiration. If the median arcuate ligament is compressing the celiac, symptoms will be emphasized upon expiration.
61
If there is a 70-99% stenosis in the left carotid siphon, which of the following is true?
A. right MCA will be high resistance
B. left vertebral flow will be high resistance
C. left MCA flow will be high resistance
D. left ICA flow will be high resistance
D
FeedBack:Distal stenosis will lead to high resistance flow proximally = ICA high resistance with siphon stenosis
62
All of the following terms refer to the areas of flow separation seen distal to a stenosis, except:
A. post stenotic turbulence
B. autoregulation
C. eddy currents
D. flow vortices
B
FeedBack:Eddy currents are also known as flow vortices. These areas of flow separation are seen with post-stenotic turbulence.
63
Patient presents 9 months after endarterectomy with an approximate 40% recurrent stenosis. What is the most likely cause?
A. Polycythemia vera
B. Neointimal hyperplasia
C. Lack of Warfarin treatment post op
D. Fibromuscular dysplasia
B
FeedBack:Neointimal hyperplasia is the most common cause of re-stenosis of a vessel that has a history of the endarterectomy procedure. It can be described as thickening of the vessel wall or over-healing after the procedure. Atherosclerosis can also cause re-stenosis but takes a much longer time to reoccur in the vessel.
64
Which of the following causes of thrombosis is associated with anatomic variations of the thoracic outlet?
A. radiation therapy treatments to the chest
B. Paget - Schroetter Syndrome
C. indwelling catheters
D. shoulder surgery
B
FeedBack:Paget - Schroetter Syndrome AKA spontaneous effort thrombosis; Most common cause of axillary/subclavian DVT in the ambulatory patient population; Related to the presence of a cervical rib and thoracic outlet syndrome; Higher incidence in the dominant arm
65
Which of the following has no effect on the severity of an arterial stenosis?
A. vessel radius
B. valvular competence
C. polycythemia vera
D. peripheral resistance
B
FeedBack:The veins contain valves, not the arteries. Valvular incompetence will not affect arterial stenosis.
66
A patient presents with episodes of left eye amaurosis fugax and right sided paresthesia. What is the most likely diagnosis in the patient with this Doppler tracing of the CCA?
Image- triphasic LT CCA
A. 80% LT ECA stenosis
B. RT ICA occlusion
C. LT CCA stenosis proximal to current point of evaluation
D. LT ICA occlusion
D
FeedBack:The Left CCA waveform demonstrates very high resistance flow with flow reversal in diastole. This is indicative of a LT ICA occlusion distally. The ipsilateral visual disturbance and contralateral limb paresthesia also support this diagnosis.
67
A carotid Doppler exam demonstrates an occlusion of the left ICA, but the distal ICA demonstrates retrograde flow. The ECA demonstrates increased diastolic flow. The ophthalmic artery on the left side demonstrates flow moving away from the transducer. Where is the collateral flow most likely coming from?
A. vertebrobasilar collateralization
B. ECA to ICA collateralization
C. ophthalmic to ophthalmic collateralization
D. cross over collateralization through the ACA
B
FeedBack:Flow reversal in the ophthalmic artery is a key sign of ECA to ICA collateral flow. If the ICA is obstructed proximally, collateral flow can refill the ICA distally. Flow moves from the left ECA - left superficial temporal artery - left supraorbital artery(reversed) - left ophthalmic artery(reversed) - distal left ICA (reversed)
68
Which of the following is least likely to be associated with renal artery stenosis?
A. CREST syndrome
B. Fibromuscular dysplasia
C. Scleroderma
D. May Thurner syndrome
D
FeedBack:May Thurner syndrome involves the compression of the left common iliac vein against the lumbar vertebrae by the overlying right common iliac artery. Scleroderma and CREST syndrome involve systemic sclerosis of multiple vessels. Fibromuscular dysplasia is also associated with stenosis of the renal arteries.
69
The majority of aortic aneurysms form in what part of the vessel?
A. Infrarenal
B. Juxtarenal
C. Suprarenal
D. Arch
A
FeedBack:Juxtarenal and suprarenal AAA can cause serious complications related to blood flow to the kidneys and renal induced HTN. These types of AAA are considered a critical finding at any size. Infra renal AAA formation is the most common AAA location. Fortunately this type of AAA can be monitored over time until it reaches 5.5-6cm in size when surgical intervention is necessary.
70
The red arrows on the image are pointing to what abnormal characteristic of the Doppler waveform?
Color image- aliasing
Spectral - vibrations with spectral broadening
A. Vibrations from post stenotic turbulence
B. Formation of a spectral window
C. Temporal tap response
D. Crosstalk artifact
A
FeedBack:The arrows indicate varied flow velocities seen in post-stenotic stenosis.
71
A tardus parvus waveform is the result of:
A. partial venous obstruction
B. significant proximal arterial stenosis
C. <50% proximal arterial stenosis
D. distal arterial obstruction
B
FeedBack:A tardus parvus waveform is associated with significant stenosis that severely decreases flow through an artery. This waveform is described as low velocity and resistance with a late systolic peak.
72
Which of the following is true regarding the difference between fibromuscular dysplasia (FMD) and atherosclerosis of the internal carotid artery?
A. Atherosclerosis forms within the adventitia of the vessel while FMD is caused by over-proliferation of the intima.
B. Atheroma formation usually occurs in the proximal segment while FMD usually affects the more distal segments of the ICA.
C. FMD usually leads to aneurysm formation while atherosclerosis leads to stenosis.
D. Atherosclerosis forms within the intima of the vessel while FMD is caused by over-proliferation of the adventitia.
B
FeedBack:FMD is related to collagen growth in the media layer of the vessel. Atheroma formation involves the media and intimal layer. Atheroma formation usually occurs in the proximal segment while FMD usually affects the more distal segments of the ICA.
73
Which of the following statements is true regarding Doppler flow evaluation of a rejected renal allograft?
A. Rejected allograft waveforms will demonstrate high resistance flow.
B. Rejected allograft waveforms will demonstrate low resistance flow.
C. Rejected allograft waveforms will demonstrate low RI and PI values.
D. Renal allograft waveforms normally demonstrate arterial flow that varies with respiration.
A
FeedBack:Doppler waveforms from arteries in a rejected allograft will demonstrate high resistance flow. The RI values for the parenchymal vessels will be elevated above 0.70.
74
Which of the following is not a characteristic of a high-grade stenosis?
A. Laminar flow just distal to the site of stenosis
B. Spectral broadening just distal to the site of stenosis
C. Extremely high velocity signals at the site of stenosis
D. Loss of pulsatility of waveform distally
A
FeedBack:Turbulent flow is demonstrated distal to a stenosis of the vessel. Spectral broadening occurs due to the variety of blood cell velocities present and this results in non-laminar flow patterns.
75
The image demonstrates the flow pattern taken in the right vertebral artery. Which of the following best describes the findings?
Image - bunny sign
A. There is an obstruction distally in the intracranial circulation
B. There is most likely a stenosis of the right subclavian artery
C. The vertebral vein flow is demonstrated not the artery.
D. There is most likely a stenosis of the left subclavian artery
B
FeedBack:The waveform demonstrates systolic deceleration. This is a sign of a proximal stenosis of the subclavian artery.
76
An end diastolic velocity of 160 cm/s is an indication of ___________ in the ICA.
A. normal flow
B. mild stenosis
C. moderate stenosis
D. severe stenosis
D
FeedBack:The end diastolic velocity (EDV) is a critical component of the evaluation of carotid stenosis. The SRU have established guidelines for possible interventions based on CUS results. According to their trials, a critical stenosis is indicated with an EDV greater than 100 cm/s. Strandness guidelines indicate significant stenosis at an EDV of 140cm/s.
77
Which of the following defines a stroke?
A. nerve conduction abnormalities within the cerebral tissue
B. acute ischemia in cerebral tissue
C. occlusion of the internal carotid artery
D. mobile piece of plaque or thrombus
B
FeedBack:Loss of blood flow to an area of cerebral tissue causes cerebral ischemia. All strokes are not caused by ICA occlusion and not every patient with an occluded ICA has a stroke.
78
Vertigo can be a common symptom related to disease of which of the following vessels?
A. MCA
B. ICA
C. ACA
D. basilar
D
FeedBack:The cerebellum is responsible for helping to maintain balance and equilibrium. The vertebral and basilar arteries give off branches that supply the cerebellum. If flow is reduced in these arteries, cerebellar ischemia can occur leading to vertigo.
79
Flow distal to a significant stenosis will exhibit which of the following characteristics?
A. higher resistance flow
B. lower resistance flow
C. increased velocity
D. increased resistive index
B
FeedBack:Flow distal to a significant stenosis will demonstrate reduced velocity and resistance
80
Which of the following is a characteristic of the Doppler waveform obtained distal to the site of stenosis in an ICA that demonstrates string flow on color Doppler?
A. blunted waveform
B. spectral window
C. decreased acceleration time
D. increased diastolic flow
A
FeedBack:Near occlusion of the ICA will lead to low velocity systolic flow with minimal diastolic flow (blunted waveform). Once total occlusion occurs, diastolic flow ceases or flow reversal occurs in the artery just proximal to the occlusion.
81
Which of the following statements is true regarding a partial venous obstruction?
A. May cause continuous flow
B. May cause phasic flow
C. Usually results in significant flow reversal during Valsalva maneuver
D. May cause increased volume of flow seen with distal augmentation
A
FeedBack:Partial DVT will decrease the flexibility of the venous wall causing a more continuous/less phasic flow pattern. Insufficiency is assessed using the Valsalva maneuver. The maneuver does not provide pertinent information related to the diagnosis of a partial DVT.
82
Which of the following would be used to describe a Doppler waveform taken in the mid ICA with a critical stenosis of the proximal segment?
A. increased resistive index
B. increased pulsatility index
C. peaked
D. damped
D
FeedBack:The Doppler waveform will be blunted and significantly damped downstream with a significant obstruction proximal to the point of insonation. There will be minimal diastolic flow, but no flow reversal.
83
What is the most common cause of cerebrovascular disease?
A. stroke
B. embolism
C. atherosclerosis
D. vasospasm
C
FeedBack:Atherosclerosis formation is the most common cause of cerebrovascular disease. Embolism formation is much less common and is usually a complication of atherosclerosis formation. A stroke is a potential complication with all types of cerebrovascular disease.
84
The PW Doppler tracing displays what level of ICA stenosis?
spectral image - PSV 450
A. 0-49%
B. 50-69%
C. 70-99%
D. 100%
C
FeedBack:The peak velocity appears to reach the top of the scale at 450cm/s. Each slash mark on the velocity scale indicates 75cm/s. The estimated end diastolic velocity appears to be about 140cm/s. These velocities indicate an 70-99% stenosis.
85
When using the transtemporal window, the probe is angled slightly posterior and the depth set at 70mm. Monophasic flow moving away from the transducer is identified with a mean flow velocity of 30cm/s. Which of the following correctly describes the findings?
A. There is abnormal flow in the vertebral artery, which most likely indicates a subclavian steal.
B. There is abnormal flow in the P1 segment of the PCA, which most likely indicates an occlusion of the contralateral MCA.
C. The waveform demonstrates normal flow for the P1 segment of the PCA from this acoustic window
D. There is abnormal flow in the P1 segment of the PCA, which most likely indicates an occlusion of the ipsilateral MCA.
D
FeedBack:The transtemporal window should demonstrate flow toward the transducer in the P1 segment of the PCA located at approximately 60-70mm depth. If the flow is reversed, it most likely indicates an occlusion of the ipsilateral MCA. The flow velocity is also reduced which can indicate a proximal obstruction.
86
Amaurosis fugax can be described as:
A. TIA of the eye
B. CVA of the eye
C. TIA of the frontal lobe
D. CVA of the frontal lobe
A
FeedBack:Because the symptom of amaurosis fugax is usually fleeting, it is termed a transient ischemic attack of the eye.
87
Which of the following describes the appearance of a waveform distal to a critical carotid stenosis?
A. increased systolic flow
B. increased diastolic flow
C. large spectral window
D. decreased diastolic flow
D
FeedBack:The waveform of the flow distal to a critical ICA stenosis will be blunted, low systolic and diastolic peaks and turbulent flow with loss of the spectral window.
88
A subclavian steal would most likely produce which of the following complications?
A. amaurosis fugax
B. systemic HTN
C. difference in brachial pressures >20 mmHg
D. congestive heart failure
C
FeedBack:Amaurosis fugax is usually related to ICA stenosis. HTN is a non-specific symptom and not a complication of a subclavian steal. Because the blood flow to the affected arm is being "pulled" from the brain, the pressure in the arm is much lower than the unaffected side. BP levels in both arms that differ more than 15mmHg are highly suspicious for the presence of a subclavian steal.
89
Which of the following describes cerebral cross-over collateralization?
A. flow from the right MCA to the left MCA through a cross over collateral vessel
B. flow from the left MCA to the right MCA through a cross over collateral vessel
C. flow from the left ACA to the right ACA through the anterior communicating artery
D. left ICA flow through posterior communicator to left vertebral
C
FeedBack:Cross over collateralization occurs when flow from the left ACA moves into the right ACA through the anterior communicating artery.
90
Which of the following statements is true regarding the Doppler tracing from the renal artery?
Image PSV - 320
EDV- 89
A. Normal flow pattern and velocity are demonstrated but an incorrect Doppler angle is used to assess the flow causing aliasing to occur
B. The renal to aortic ratio is most likely below 3.5
C. Normal flow pattern and velocity are demonstrated
D. According to RAS diagnostic criteria, Stenosis > 60% is demonstrated
D
FeedBack:Renal artery stenosis > 60% is indicated when the PSV is greater than 1.8m/s and the renal aortic ratio is over 3.5. A 60% stenosis is considered significant and treatment is required. There are no other diagnostic criteria used to stage RAS at 75% and 85% stenosis etc.
91
Which of the following ultrasound findings is least likely to be seen with PHACE syndrome?
A. Paraganglioma between the ECA and ICA on the left
B. Absence of the right ICA
C. Basilar artery stenosis
D. Aberrant origin of the left ICA
A
FeedBack:PHACE Syndrome is a congenital disorder that includes: Posterior fossa malformations (cranial malformations such as Dandy Walker malformation), Hemangiomas, Arterial anomalies, Coarctation of the aorta and other cardiac anomalies, Eyes (ocular anomalies). Associated findings identified on a cerebrovascular ultrasound exam include:
Arterial stenosis or occlusion of cerebral arteries
Absence or moderate-severe hypoplasia of the large cerebral arteries
Aberrant origin or course of the large cerebral arteries
Saccular aneurysms of the cerebral arteries
92
What is the minimum % ICA stenosis that is considered hemodynamically significant and treatment is recommended?
A. 80%
B. 95%
C. 70%
D. 75%
C
FeedBack:A hemodynamically significant stenosis requiring intervention is defined as 70-99% blockage of the ICA.
93
If there is a left subclavian steal, which brachial artery evaluation will be abnormal?
A. Right brachial will have a lower BP and a blunted/monophasic waveform
B. Left brachial will have a lower BP and a blunted/monophasic waveform
C. Right brachial will have a higher BP and a blunted/monophasic waveform
D. Left brachial will have a higher BP and a triphasic waveform
B
FeedBack:If there is a left sided steal, this indicates the left subclavian artery has an occlusion at the origin. The left vertebral artery originates from the left subclavian artery, just distal to its origin from the arch. The left vertebral artery now receives no antegrade flow toward the head, due to the subclavian blockage.
Blood flows toward the head in the right vertebral artery to join the left vertebral artery to form the basilar artery. Some flow from the right vertebral reverses into the left vertebral artery to feed the left subclavian artery and arm.
The BP in the left arm drops due to the blood flow coming in from the low resistance, cerebral circulation. The distal arm pressure will decrease to allow flow to enter the "empty" vessels above, in a retrograde fashion.
Vertebral flow is low resistance and monophasic. The Doppler evaluation of the left arm will demonstrate these characteristics which are abnormal for an extremity.
94
Which of the following correctly describes carotid dissection?
A. Commonly associated with Paget Schroetter syndrome
B. Dissection is more common in the extracranial ICA than the intracranial ICA
C. Dissection is more common in the Circle of Willis than the extracranial arteries
D. Always associated with trauma
B
FeedBack:Dissection is more common in the extracranial ICA than the intracranial ICA
95
Localized redness and warmth of the distal calf is most commonly associated with:
A. Acute arterial occlusion of the popliteal artery
B. Acute DVT formation in the popliteal vein
C. Cellulitis
D. Anterior compartment syndrome
C
FeedBack:Redness and warmth are most commonly seen with cellulitis but can be a symptom of acute DVT.
96
The most common location of valvular insufficiency is:
A. great saphenous and common femoral vein junction
B. superficial and deep femoral vein junction
C. short saphenous vein
D. Popliteal vein
A
FeedBack:The most common location of valvular insufficiency is at the SFJ (junction of great saphenous and common femoral vein junction).
97
Which of the following is a common occurrence post-endarterectomy?
A. Neointimal hyperplasia
B. Intracranial hemorrhage
C. CHF
D. Intimal dissection
A
FeedBack:Neointimal hyperplasia refers to the overgrowth of normal tissue in response to the endarterectomy. This is a common cause of re-stenosis of a vessel that previously underwent endarterectomy.
98
Which of the following is associated with spectral broadening?
A. laminar flow
B. blunted waveform
C. increased bandwidth
D. pulsatile flow
C
FeedBack:Bandwidth refers to the difference between the highest and lowest frequencies in the pulse. Laminar flow has a narrow bandwidth of reflected signals because the blood cells are all moving at relatively the same speed. This allows for the display of a spectral window on the tracing. With turbulent flow, the blood cells are moving at many different velocities. This produces a wide bandwidth of reflected signals and the spectral window fills in.
99
The most significant complication seen with DVT is _______________________.
A. Pulmonary embolism
B. Varicose veins
C. Incompetent valves
D. Cardiac Tamponade
A
FeedBack:A pulmonary embolism occurs when a piece of thrombus breaks off and travels to the lungs. This occludes the bronchial artery and leads to the inability of the lungs to replace the oxygen in the blood. 15% of all cases of sudden death are PE related.
100
What is the expected waveform characteristic if the Doppler sample volume is placed at the same location as the calipers?
Image long measurement of lumen from stenosis vs vessel - .54 and .13
A. triphasic with increased peak systolic and end diastolic velocities
B. blunted waveform with increased diastolic flow
C. increased peak systolic velocity and decreased end diastolic velocity
D. monophasic with increased peak systolic and end diastolic velocities
D
FeedBack:The calculated diameter stenosis is 76% which indicates a severe stenosis. The waveform at the stenosis will indicate a monophasic waveform with increased systolic and diastolic flow pattern.
101
All of the following are true regarding venous insufficiency, except:
A. Most commonly occurs due post-phlebitic syndrome
B. Most common venous disease of the extremities
C. Most common complication of DVT
D. Most commonly occurs at the saphenofemoral junction at the groin
A
FeedBack: Venous insufficiency most commonly occur due to primary venous disease such as, malformation of the venous valves, increased volume of flow in the system (pregnancy) or obesity. Primary varicosities are more common than the secondary type that is usually related to a prior DVT.
102
A patient with aortic coarctation distal to the left subclavian artery origin will demonstrate:
A. bounding pedal pulses
B. systemic HTN with increased brachial pressures
C. increased bilateral ABIs
D. no change in ankle pressures with exercise
B
FeedBack:Coarctation refers to congenital narrowing of the aorta. It most commonly occurs distal to the origin of the left subclavian artery. It causes decreased flow distal to the obstruction and monophasic flow with continuous flow in diastole is identified in the abdominal aorta. Coarctation causes lower extremity ischemia, decreased bilateral pedal pulses, and decreased bilateral ABIs. Because the arch is proximal to the obstruction, flow to the head and neck is usually normal. Systemic HTN is usually present because the coarct causes renal ischemia and the renin-angiotensin system is activated causing increased systemic pressure.
103
Venous perforators with a diameter of _______________ or greater will usually demonstrate reflux.
A. 4mm
B. 2cm
C. 6mm
D. 2mm
A
FeedBack:Normal perforator diameter is 2mm.
104
The image demonstrates a _____________________ aneurysm.
long aneurysm that tapers
A. Saccular
B. Berry
C. Fusiform
D. Dissecting
C
FeedBack:Note the uniform dilatation on the anterior and posterior aspects of the vessel consistent with a fusiform AAA.
105
In a post-phlebitic patient with perforator disease, what happens to the venous pressure in the small saphenous vein with calf muscle contraction?
A. decreases significantly
B. increases
C. decreases only slightly
D. no change in pressure occurs in the superficial venous system with muscle contraction
B
FeedBack:In the normal patient, the calf muscle contracts and pressure in the superficial system drops as blood moves toward the heart and through perforators into the deep system. A post phlebitic patient usually has increased deep vein pressure due to residual obstruction and incompetent valves. The increased deep venous pressure limits inflow from the superficial system and causes superficial vein/perforator dilatation with valvular incompetence. Perforator incompetence allows flow reversal into the superficial system. When the muscle contracts, deep venous flow is pushed into the superficial system through the incompetent perforators. This causes an increase in the superficial system pressure with muscle contraction due to the deep venous inflow.
106
All of the following are abnormal flow changes caused by congestive heart failure, except?
A. decreased ankle pressures
B. decreased velocities in the bilateral common carotid arteries
C. biphasic portal flow
D. pulsatile flow in the proximal hepatic veins
D
FeedBack:The hepatic veins normally demonstrate pulsatile or triphasic flow due to the ripple effect from cardiac motion.
107
Which of the following Doppler findings would indicate significant venous hypertension?
A. Increased systolic velocities with decreased diastolic velocities
B. Triphasic flow patterns in the lower extremity deep veins
C. Absence of flow in the deep veins on deep expiration
D. Continuous flow patterns in the lower extremity deep veins
B
FeedBack:Pulsatile venous flow in the deep veins of the lower extremity indicates increased venous pressures (venous HTN). CHF, electrolyte imbalance and kidney dysfunction can lead to venous HTN. Continuous flow patterns in the veins can be a sign of chronic obstruction proximally.
108
Which of the following terms would be used to describe flow within an abdominal aortic aneurysm?
A. plug flow
B. triphasic flow
C. high resistance flow
D. non-laminar flow
D
FeedBack:Flow within the AAA will be decreased in resistance and turbulent due to the swirling effect. Normal aortic flow is called plug flow. Flow in a AAA would be of many different velocities and is considered non-laminar.
109
Wernicke's aphasia is defined as:
A. Inability to speak but can understand others
B. Inability to swallow solid foods
C. Inability to swallow liquids
D. Inability to understand speech, speak, or follow directions
D
FeedBack:Wernicke's aphasia (AKA receptive aphasia) is defined as the inability to understand speech, speak, or follow directions.
110
This color Doppler image demonstrates:
Image - Lt vert blue, Rt vert red
A. normal bilateral vertebral flow
B. reversed right vertebral artery flow
C. subclavian steal
D. left vertebral stenosis
C
FeedBack:When evaluating the vertebral arteries, always take note of the color map and related direction of flow. Note the right vertebral is flowing in the normal direction toward the brain while the left vertebral demonstrates flow reversal.
111
Which of the following would not result in a carotid bruit?
A. 60% ECA stenosis
B. 75% ICA stenosis
C. 99% ICA stenosis
D. aortic valve stenosis
C
FeedBack:99% stenosis will have minimal antegrade flow (string sign) that will not cause an audible bruit.
112
The image demonstrates which of the following abnormalities?
Image- bifurcation with flow fill in minus a small area in bif that appears to be soft plaque dipping down into lumen
A. ulceration only
B. dissection and stenosis
C. stenosis only
D. ulceration and stenosis
D
FeedBack:The ridge of atherosclerosis is ulcerated and extends into the center of the lumen causing stenosis. The crater or ulceration combined with the adjacent stenosis leads to a significantly increased risk of embolization. A dissection is an acute finding.
113
This Doppler tracing taken from a branch of the aorta demonstrates:
Image - AO in long axis, Doppler on small branch off AO,
Spectral - spectral broadening w PSV 500
A. Critical stenosis of the celiac axis
B. Hemodynamically significant stenosis of the right renal artery
C. Normal celiac flow with top normal PSV
D. Hemodynamically significant stenosis of the left renal artery
A
FeedBack:Note the spectral broadening, increased PSV over 5 m/s (<2.0 NL) and increased diastolic flow. These Doppler characteristics should lead to a diagnosis of hemodynamically significant stenosis of the celiac artery. The renal arteries would not normally be evaluated with Doppler in the longitudinal view of the aorta. They also would not originate from the anterior aorta.
114
Which of the following can lead to an increase in the frequency shift detected in the common femoral artery?
A. 80% stenosis of the common femoral artery
B. Proximal superficial femoral artery occlusion
C. 80% stenosis of the superficial femoral artery
D. Decreased probe frequency
A
FeedBack:Stenosis in the CFA will increase the detected frequency shift (and calculated velocity). Using a higher frequency probe will increase the detected frequency shift. Significant stenosis or occlusion of the SFA will reduce the detected frequency shift (velocity) in the CFA.
115
A pulsatility index of > 1.2 in the cerebral vessels indicates:
A. normal flow resistance
B. vasospasm
C. mildly decreased resistance
D. severely decreased resistance
B
FeedBack:The greater the PI, the greater the variation on velocity throughout the cardiac cycle. The greater the PI, the higher the resistance to flow. Cerebral vessels should normally have a low PI value. Vasospasm causes increased resistance in vessels.
116
Which of the following statements is true regarding the image of the aorta?
AAA with echogenic material along the sides of the lumen
A. The true lumen is the anechoic space in the middle of the vessel. The total AP dimension of the AAA size is the distance between the actual vessel walls.
B. Embolism formation has occurred in the area of dilatation due to swirling and stasis of blood.
C. The AAA shown requires immediate treatment due to its location proximal to the renal arteries.
D. All of the above
A
FeedBack:It is important to measure the AAA size and the actual lumen size, if thrombus accumulation is present within the AAA.
117
A patient presents with bilateral distention of the internal jugular veins and arm swelling. The lower extremities are normal on physical examination. Which of the following could be a cause for these symptoms?
A. CHF
B. Subclavian steal syndrome
C. Interrupted IVC
D. SVC Syndrome
D
FeedBack:SVC syndrome refers to the progressive obstruction of the SVC which causes venous dilatation of the upper extremities and neck. Doppler evaluation of the bilateral internal jugular veins will demonstrate continuous flow patterns. Respiratory phasicity and cardiac pulsatility will be lost.
118
When performing a carotid exam, the proximal ICA is limited in color and Doppler evaluation by heavy calcification of the arterial wall. The mid ICA segment demonstrates biphasic flow with the main component of flow moving in retrograde fashion. Which of the following describes the CCA flow pattern that will be identified?
A. Normal appearance due to distal collateral flow in ICA
B. Triphasic flow with increased velocity
C. Increased velocity with decreased resistance
D. Triphasic flow with decreased velocity
D
FeedBack:There is most likely an occlusion of the proximal ICA. The retrograde flow in the mid ICA is due to collateralization leading to backfill of the vessel. The CCA will demonstrate a high resistance waveform due to the ICA obstruction.
119
The most common site for hepatic artery stenosis in a transplant is _______________________________________.
A. at the native hepatic artery anastomosis site located just inside the liver near the portal bifurcation
B. at the common hepatic artery bifurcation located just inside the liver near the portal bifurcation
C. at the origin of the native hepatic artery from the celiac axis
D. at the native hepatic artery anastomosis site located just outside the hilum of the liver
D
FeedBack:The donor hepatic artery is connected to the native hepatic artery just outside the hilum of the donor liver. The most common site for arterial stenosis is at the anastomosis site. Myointimal hyperplasia can lead to stenosis at the anastomosis site due to "over-healing" of the connection.
120
The most common location of atherosclerotic formation in the cerebrovascular system?
A. ophthalmic and orbital arteries
B. carotid bifurcation
C. vertebrobasilar system
D. circle of Willis
B
FeedBack:The most common location of atherosclerotic formation in the cerebrovascular system occurs at the carotid bifurcation.
121
If a left ICA occlusion is present, which of the following statements is true?
A. The right ophthalmic artery will demonstrate decreased or absent flow
B. The left MCA will demonstrate decreased or absent flow.
C. The right MCA flow will be decreased or absent with normal flow in the right internal carotid siphon.
D. The right MCA flow will be decreased or absent with flow reversal in the right internal carotid siphon.
B
FeedBack:The ICA supplies the ipsilateral MCA and ophthalmic artery with blood. If the ICA is occluded the flow in these vessels will be absent unless collateral vessels present which would lead to minimal flow in the vessels.
122
The diagnosis of AAA is made once the aorta AP or width dimension exceeds _____.
A. 2.5cm
B. 3.0cm
C. 3.5cm
D. 4.0cm
B
FeedBack:The diagnosis of AAA is made once the aorta AP or width dimension exceeds 3.0cm.
123
Which type of aortic aneurysm is associated with an infection of the arterial wall?
A. Berry
B. Mycotic
C. Saccular
D. Ectatic
B
FeedBack:A mycotic aneurysm is caused by infection of the arterial wall which weakens it and allows aneurysm formation.
124
Which of the following can lead to a false negative diagnosis of ICA stenosis?
A. Congestive heart failure
B. Anemia
C. Increased cardiac output
D. Tortuosity
A
FeedBack:Decreased cardiac output can lead to decreased flow velocities throughout the body. CHF can lead to a false negative diagnosis for stenosis due to abnormally decreased velocities in the carotid system. Anemia causes the blood to thin and flow velocities would increase.
125
Which of the following is a cause for a CVA?
A. IJV thrombus or ICA thrombus
B. pulmonary embolism or pulmonary HTN
C. pulmonary HTN or systemic HTN
D. ischemia, hemorrhage or vasospasm
D
FeedBack:Cerebral ischemia, hemorrhage or vasospasm can lead to reduced flow to the brain causing stroke symptoms
126
What statement describes a TIA?
A. Stroke symptoms lasting 2-4 weeks
B. Stroke symptoms lasting 24 hrs - 2 weeks
C. Stroke symptoms lasting 24 hrs - 72 hrs
D. Stroke symptoms lasting 24 hrs or less
D
FeedBack:
TIA = Stroke symptoms lasting 24 hrs or less
CVA = Stroke symptoms lasting more than 24hrs
127
Renal artery stenosis is considered hemodynamically significant when it is greater than ______.
A. 50%
B. 60%
C. 70%
D. 80%
B
FeedBack:Renal artery stenosis is considered hemodynamically significant when it is greater than 60%.
128
According to the attached color map, what color will the blood be demonstrated that is moving toward the probe at an average speed of 100cm/s?
Color map - yellow/red on top, Blue/white on bottom
max- 0.43
A. blue
B. yellow
C. white/light blue
D. red
C
FeedBack:The speed of the blood exceeds the scale displayed therefore aliasing of the color display will occur. The white or light blue color of the blue color bar will be seen and is related to the "wrap around" of the color display.
129
Which of the following is a sign or symptom of chronic DVT?
A. Warmth
B. Positive Homan's Sign
C. Redness
D. Brawny Discoloration
D
FeedBack:Hyperpigmentation refers to brawny discoloration of the distal 1/3 of the calf. It is caused by cell debris and waste accumulating in the tissues outside the veins. Homan's sign refers to calf pain with quick dorsiflexion of the foot. This can be a sign of a DVT with the calf pain relating to the inability to pump out the blood when the muscle is quickly contracted. Swelling, warmth and redness are all related to venous stasis in the vessels below the area of DVT.
130
All of the following signs/symptoms are commonly associated with a venous stasis ulcer, except?
A. located at the medial malleolus
B. severe pain
C. discoloration of the affected area
D. oozing
B
FeedBack:Venous ulcers are usually mildly painful.
131
Congestive heart failure causes increased pulsatility in all of the following, except?
A. superficial femoral artery
B. portal vein
C. iliac veins
D. hepatic veins
A
FeedBack:The decreased cardiac output can decrease pulsatility in the distal arterial system.
132
What findings are displayed on the image?
rt vert - antegrade
lt vert biphasic, mostly retrograde
A. partial subclavian steal on the left side
B. abnormal left waveform associated with temporal arteritis
C. partial subclavian steal on the right side
D. bilateral normal vertebral waveforms
A
FeedBack:Flow in the left vertebral artery is reversed. Some flow reversal is present in diastole which indicates a partial steal. If the flow is reversed throughout the cardiac cycle, a complete steal is present.
133
Which cerebral vessel is most commonly involved in an acute cerebral ischemia?
A. MCA
B. PCA
C. ACA
D. basilar
A
FeedBack:The MCA is most commonly involved in an acute occlusion and cerebral ischemia due to its connection to the ICA.
134
What is causing the waveform displayed?
antegrade flow with irregular spacing of waveforms
A. distal stenosis
B. arrhythmia
C. proximal stenosis
D. subclavian steal
B
FeedBack:Note the difference in timing of the systolic peaks of the waveform. This indicates a cardiac arrhythmia. In this case atrial fibrillation is present. The velocity demonstrated is normal for the vertebral arteries.
135
An abnormality in all of the following vessels could potentially be related to vasculogenic impotence, except?
A. internal iliac artery
B. external iliac artery
C. aorta
D. common iliac artery
B
FeedBack:The external iliac artery supplies blood to the leg. The internal iliac artery supplies blood to the branches that supply the penis. If there are flow abnormalities in the aorta, internal iliac artery or common iliac artery, this can lead to vasculogenic impotence.
136
The images demonstrated are from a mesenteric Doppler exam. The patient was NPO for the exam. The IMA was also evaluated and demonstrated a monophasic, high resistance waveform with a peak velocity of 150cm/s. What do these findings indicate?
A. Normal SMA and IMA flow but a tardus parvus waveform is identified in the celiac axis.
B. Normal exam
C. mesenteric ischemia
D. SMA stenosis
D
FeedBack:Mesenteric ischemia requires stenosis or occlusion of at least two of the mesenteric arteries. (Celiac, SMA, or IMA) Only SMA stenosis is present. The other velocities are normal for the IMA and celiac.
