Quiz 3 (vessel recognition) Flashcards
what is the intimal wall thickness?
less than or equal to 0.9
what axis is the intimal wall thickness measured?
longitudinal image (SAG)
specular reflection
Demonstrate a sharp line that emanates from the intimal surface
what is the black line on an carrotid on a SAG image indicate?
tunica media
what does the outermost white line on a SAG carotid artery indicate?
tunica adventitia
what are the characteristics of low pulsatility?
- broad systolic peak
- forward flow throughout diastole
- always completely above or below baseline (depending on direction of flow)
- low peripheral resistance flow as in the carotid, vertebral, and renal arteries
- monophasic waveform
what are the characteristics of moderate pulsatility?
- tall and sharp systolic peak
- forward flow through all of diastole
- diastolic flow is relativity less than seen in low pulsatility waveforms
- flow is typically seen ECA
- dicrotic notch is found
- temporary cessation of forward flow
- biphasic waveform
what does the ECA supply?
- face and neck
- SMA during fasting
what is the dicrotic notch?
transition from systole to diastole. It is a normal finding that represents the closure of the aortic valve
what is the dicrotic notch thinking about flow?
temporary cessation of forward flow followed by resumption of forward flow driven by the elastic rebound of the arterial wall
what are the characteristics of high pulsatility?
- narrow, tall, sharp, systolic peaks
- brief flow reversal, then brief flow reversal
- triphasic waveform
- typically seen in resting state peripheral arteries
monophasic waveform
all flow is above baseline
biphasic waveform
single antegrade and single retrograde
triphasic waveform
flow is systole is above baseline then reversed segment in diastole below baseline and third component of diastolic flow above the base line
what is the CCA identity?
- moderate pulsatility
- close to baseline
- low diastolic flow
- sharp upstroke
how do you locate the CCA?
place probe TRV on the anterolateral neck at the level of the thyroid. It is seen lateral to the lobe
what are the characteristics of the ICA to differentiate it from the ECA?
- lower pulsatiity
- rounded peak window
- high diastolic flow
wat are the characteristics of the ECA to differentiate it from the ICA?
- higher pulsatility
- higher upstroke
- closer to baseline
- lower diastolic flow
how do you locate the ICA and ECA?
follow the CCA upward in TRV. It will bifurcate into ECA and ICA. The vessel with the bulb is ICA-lateral. The vessel that is narrower is ECA-medial
what are the characteristics of the vertebrals?
- low pulsatility
- similar to ICA with lower velocity
- forward flow throughout diastole
- travels cephalad through transverse foramina of C6 to C2
how do you locate the vertebral artery?
- find the CCA sagitally in anterolateral plane
- angle probe laterally slowly until vertebrals bodies are seen
- the artery and vein will be seen within gaps of vertebrae
where is the subclavian located?
posterior to clavicle
what are the characteristics of the subclavian artery?
- high pulsatility, high resistant signal
- sharp systolic upstroke
- triphasic signal
- reverse diastolic component
- forward diastolic component
describe the appearance of the monophasic arterial flow?
- spectrum is completely above baseline
- systolic and diastolic portions
- flow does not touch baseline (0)
- good example is the low resistant ICA
describe the appearance of the biphasic arterial flow?
- all systolic portion is above baseline
- diastolic flow crosses the baseline and is below it
- high resistance flow pattern since flow reaches 0 and has negative component
- good example is abnormal triphasic waveform
describe the appearance of the triphasic arterial flow?
- systolic phase is above baseline
- first diastolic component is below baseline
- third component of diastolic flow is above baseline
- high resistant flow patterns
- good example is subclavian and femoral arteries
what does some abnormal flow pattern signify?
- approaching stenosis
- stenosis
- post stenosis
what are some abnormal flow patterns?
- internalization of ECA-antegrade ECA
- —(CCA occlusion/ICA occlusion)
- externalization of CCA
- Thud flow
- Tardus Parvus waveform
- severe aortic regurgitation
what is the difference between 2 waveforms when they are both low resistant and one has a clean window and one does not?
clean window is larger superficial artery such as CCA and broadened is deeper vessels such as renal artery
what is a stenosis?
narrowing of the arterial lumen, causing a hemodynamically significant change in flow
what may happen if an stenosis or occlusion occurs?
collateralization
where does plaque commonly form and what does it involve?
Common carotid bifurcation and it involves the:
- distal CCA
- prox ECA/bulb
- prox ICA
what is plaque categorized as?
- homogenous
- soft
- heterogenous
- ulcerated
- calcified
Plaque should be carefully evaluated to determine the:
- extent
- location
- surface contour
- texture
- assess degree of luminal stenosis
- evaluate in SAG and TRV
- use gray scale ultrasound
CIMT
intima-media thickness
what is plaque a combination of?
increased thickness of intima-media layers and by echogenic material that encroaches on the lumen
plaque characterization-homogenous
-uniform and smooth surface
plaque characterization-calcified
produces posterior acoustic shadowing (asymptomatic patients)
plaque characterization-heterogenous
complex echo pattern-contains one or more sonolucent areas
plaque characterization-ulcerated
- focal depression or break in plaque surface
- irregular border contour
fibromuscular Dysplasia
growth of cells in walls causing narrowing
carotid pseudoaneurysm
collection of blood between media and adventisa
carotid/vertebral artery dissection-intimal flap
flap in lumen, separation of wall
takayasus, temporal and giant cell arteritis
inflammation of vessel walls, lumen gets narrow (chemo)
Raynaud’s phenomenon
blood flow is reduced to fingers and toes
Carotid body tumor
at bifurcation tumor causes widening and highly vascular and usually benign
thoracic outlet syndrome
compression of nerves, arteries, or veins from extra cervical rib
endarterectomy
surgical treatment for stenosis (peel plaque off)
carotid setting
go through artery and place stent in narrowing and widen back up
what is the gray scale characteristics of vessel?
- normal carotid has smooth vessel walls
- no appreciable plaque in lumen
- intimal-media layer is clearly visable
- uniform throughout vessel
- lumen is anechoic
- occasional reverberation artifacts in lumen because of IJV
what are the grayscale images in TRV gray scale?
- prox
- mid
- distal
- bifurcation
- prox ICA/bulb
what are the grayscale images of SAG gray scale?
- prox
- mid
- distal
- bifurcation with ICA and ECA (or separate)
what is the sonographers role of scanning carotids?
- assessing lumen for presence of wall thickening and plaque
- measuring the AP wall thickness
- follow protocol for carotid
- images are taken on the left and right side
when using color doppler, which axis do we access first?
TRV
how many axis do we take pictures with colour doppler?
2 (SAG and TRV)
using duplex flow where do we assess flow?
SCA -prox -mid CCA -distal ECA (w temporal tap) Bulb ICA -prox -mid -distal
what do you do if you noticed a area of plaque?
run the doppler sample carefully through the potential stenosis
where do you document increased doppler flow signal at levels of stenosis?
- proximal to stenosis (asses flow change)
- within stenosis (highest velocity)
- distal to stenosis (detect post stenotic turbulence)
- further downstream for tardus parvus waveform
when measuring velocity within stenosis, how many samples do you take?
3
what do you measure on all vessels?
-PSV (peak systolic velocity)
-EDV in ICA stenosis
for grading purposes
how do you document vertebral artery?
flow and direction with triplex doppler
what must be assessed if there is a reversal of flow in the vertebral artery?
ipsilateral (same side) SCA must be assessed for stenosis/occlusion
-also the ECA flow PSV
where can the SCA be accessed?
level of superior clavicle in the mid portion
what should the signal be in the SCA, INN A?
high resistant and triphasic
what does the water hammer associate with?
aortic regurgitation
what is subclavian steal syndrome?
blood in vertebrals retrogrades (reverses) flow
if SCA stenosis or occlusion is suspected then what do we access?
vertebral artery for subclavian steal syndrome
what is the average normal velocity in SCA?
140 cm/s
what is the average normal velocity in CCA?
80-100cm/s
what is the average normal velocity in ICA?
less than 125 cm/s
what is the average normal velocity in ECA?
120 cm/s
what is the average normal velocity in vertebrals?
20-60 cm/s
signal nomenclature of SCA?
high resistant
high pulsatiity
signal nomenclature of CCA?
mix of ECA and ICA
medium pulsatiity
signal nomenclature of ICA?
low resistant
low pulsatiity
signal nomenclature of ECA?
high resistant signal
high pulsatility
signal nomenclature of vertebral?
low resistant
low pulsatility
grading ICA stenosis-normal
less than 125 cm/s
minimal or no spectral broadening
grading ICA stenosis-1-15%
less than 125 cm/s
spectral broadening during deceleration phase of systole
grading ICA stenosis-16-49%
less than 125 cm/s
spectral broadening throughout systole
grading ICA stenosis-50-79%
greater or equal to 125 cm/s with end diastolic less than 140 cm/s
-marked spectral broadening
grading ICA stenosis-80-99%
greater than 125 cm/s with end diastolic greater than 140 cm/s
-marked spectral broadening
grading ICA stenosis-occlusion
no signal
does ECA have little or lots of diastolic flow?
little diastolic flow
does ICA have little or lots of diastolic flow?
high diastolic flow
where is low resistant flow in the body?
cephalad (towards head or superficial) throughout cardiac cycle
what does high resistant waveform look like?
flow-forward flow in systole-low or reversed in diastole and third component forward flow above the baseline
does areas having high metabolic flow need low or high resistant flow?
low resistant flow
what factors affect ICA waveform?
- atheroma/plaque
- tortuosity
- aortic valve disease
- aortic arch/innominate disease
- distal carotid siphon disease
- intracranial vessel disease
- contralateral carotid occlusion
- high cardiac output states
what are some problems and pitfalls of waveform?
- Incorrect doppler sample volume(gate) position or size
- Doppler angle too large > 60 degrees
- Doppler settings too high for low velocity, low volume flow
- Tortuous vessels
- High grade stenosis
- Calcified plaque
how do you make sure you have the correct sample volume setting?
- Sample volume with angle correct at 60 degree
- Located centrally within vessel and parallel to walls
- Color flow box angled correctly
- Spectral waveform set correctly with baseline and velocity scale
where is a lumen with plaque measured?
in TRV
what are causes of pulsatile neck masses?
- Normal but prominent carotid artery bulb
- Ectatic carotid,brachiocephalic or subclavian artery
- Aneurysm of carotid artery
- Carotid body tumor
- Enlarged lymph node adjacent to carotid sheath
atherosclerosis
a chronic progressive disease
what does plaque of atherosclerosis consist of?
deposits of cholesterol and other lipids, calcium and large inflammatory cells called macrophages
plaque
sticky yellowish deposits
what problems can plaque cause?
- protrude into the artery causing a partial or complete obstruction to flow
- rupture causing a thrombus to form
- weaken the wall and cause aneurysm
atherosclerosis coronary arteries
angina, heart attack
atherosclerosis cerebrovascular circulation
stroke
atherosclerosis renal arteries
kidney disease
atherosclerosis aorta
aortic aneurysm
atherosclerosis peripheral arteries
leg claudication (pain when walking)
what are risk factors for atherosclerosis?
- smoking
- Hyperlipidemia
- Hypertension
- Diabetes
- Obesity
- Fam history
- Psychosocial factors
- unhealthy diet
- gender
- age
what high blood pressure can lead to the heart working harder and harm the arteries?
over 140/90mm
what is normal blood pressure?
120/80mm
how does smoking effect your arteries?
nicotine and carbon monoxide in cigarette smoke damages the epithelium
hyperlipidemia
elevated levels of cholesterol and triglycerides in the blood damages the epithelium
what do most diabetics die from?
heart attacks caused by atherosclerosis
what is the good cholesterol?
High Density Lipoprotein-HDL
what is the purpose of HDL?
maintains the inner walls-endothelium of blood vessels
what is good levels of HDL?
over 60mg/dl
what is the bad cholesterol?
Low Density Lipoprotein-LDL
why is LDL bad?
deposits in the walls of arteries and over time grows into plaque
what is plaque made up of?
cholesterol, cells, and debris
why is obesity a risk factor for atherosclerosis?
excess weight strains the heart and increases the risk
-associated with high triglycerides and cholesterol
what are the signs of a heart attack?
- chest discomfort
-pressure, squeezing, fullness, or pain, burning or heaviness - discomfort in the upper body
-neck, jaws, arms, and back - shortness of breath
4.sweating
5.nausea
6.light headedness
CALL 911
what is the leading cause of death in the US?
heart disease
what is the second leading cause of death in the US?
cancer
what is the third leading cause of death in the US?
stroke (secondary to atherosclerosis)
what is another name for stroke?
cerebrovascular accident (CVA)
what are the levels of LDL?
greater than 160 mg/dl is too high
