Vascular 1

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created 5 years ago by Annabelle
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updated 5 years ago by Annabelle
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1

Where does the CCA bifurcate?

at the level of the

superior thyroid cartilage

2

What is the first branch of the subclavian artery?

vertebral

3

What does systemic system on each side of the neck imply?

waveform should be the same on each side.

4

What is the function of the extracranial cerebrovascular system function?

Supply blood flow to

cerebral hemispheres

eyes

face muscles

forehead

scalp

5

Where does the vertebrals supply blood to?

  • Brain stem
  • Cerebellum
  • Undersurface of the cerebral hemispheres
6

Where does the carotid artery supply blood to?

  • Eyes
  • Anterior 2/3 of brain
7

Name the branches of the aortic arch

  • Right Innominate/Brachiocephalic
    • Right CCA
    • Right Subclavian artery
  • Left CCA
  • Left Subclavian artery
8

Where does the ECA supply blood to?

face

neck

scalp

9

Name the branches of the ECA.

  • Superior thyroid
  • Ascending pharyngeal
  • Lingual
  • Facial
  • Occipital
  • Posterior auricular
  • Superficial temporal
  • Maxillary
10

Name the 4 divisions of the ICA.

  • Cervical
  • Petrous
  • Cavernous
  • Cerebral
11

Explain the location of the ICA compared to the ECA.

posterior and lateral

12

What type of flow is expected in the bulb of the carotid?

turbulent

13

What is the flow of the vertebral arteries?

Posterior circulation

  • 1st branch of the SCA
  • Pass cranially through the fossae of the transverse processes of the upper 6 cervical vertebrae
  • Enters the skull through the foramen magnum, joins contralateral vertebral
  • Together they form the Basilar artery (intracranially)
14

What do the two vertebrals form?

Basilar artery

15

What is the diameter of the CCA?

5-6 mm

16

What is the diameter of the ICA?

4-5 mm

17

What is the diameter of the ECA?

3-4 mm

18

What is the diameter of the vertebral artery?

2-3 mm

19

How much of the carotid's blood enters the brain via the ICA?

80%

20

How much of the carotid's blood supplies the face and neck via the ECA?

20%

21

Explain the waveform of the CCA

card image

Mimics both ICA and ECA waveforms

22

Explain the waveform of the ICA

card image

low resistant - constant forward flow

Forward flow throughout the cardiac cycle

23

Explain the waveform of the ECA

card image

high resistant

steep forward stroke

Forward flow during systole, low or reverse diastolic component

24

Explain the waveform of the vertebral artery

card image

low resistant

25

What is resistance determined by?

diastole

less diastole = high resistance

26
card image

What causes tortuous vessels?

can be born this way

can happen over time as people age they shrink

*elevation can result but state that vessel was tortuous

27
card image

Which is the left CCA?

right

28

On what side is the notch in long?

superior

29

On what side is the notch in transverse?

patient right

30

Where is the notch when imaging the right cerebrovascular system in transverse,

posterior

31

When imaging the left cerebrovascular system in transverse, where will the notch be?

card image

anterior

32

How should plaque be measured?

card image

transverse measurement

lumen vs true lumen

33

Why is plaque measured in transverse?

card image

Longitudinal estimation of stenosis from B-mode image is usually unreliable, use transverse image.

*This minor plaque can be made to appear more or less stenotic in longitudinal view

34

Plaque Morphology

card image
35

How do you tell the difference between the ICA and ECA?

  • Anatomy
    • posterior position of ICA
    • branches of ECA
    • ICA size: not reliable when diseased
  • Doppler waveforms & sounds
    • ICA = low resistance
    • ECA = high resistance
36

ICA lies _________ in the neck (95%)

card image

ICA lies posterior in the neck (95%)

37

ECA position, whether lateral, anterior or medial, is _________.

card image

ECA position, whether lateral, anterior or medial, is variable

38
card image

...

39
card image

...

40
card image

...

41

What are the four sets of the ECA branches?

Anterior

Posterior

Ascending

terminal

42

What are the anterior branches of the ECA?

  • Superior Thyroid
  • Lingual
  • External Maxillary (facial)
43

What are the posterior branches of the ECA?

  • Occipital
  • Posterior Auricular
44

What are the ascending branches of the ECA?

Ascending Pharyngeal

45

What are the terminal branches of the ECA?

  • Superficial Temporal
  • Internal Maxillary
46

What is Plaque?

card image

Atherosclerotic material that builds up on the walls of arteries

  • It restricts flow
  • It can break loose
47

What is a lumen?

card image

The flow space within a vessel

48

What is residual lumen?

card image

amount of flow space after accounting for the plaque

49

What is a Bifurcation?

card image

The point of vessel division

  • can be a common site of stenosis
50

What are Collateral Circulation?

  • Alternate pathways for blood flow that become functional after obstruction.
  • Detours
51

What is an Embolus?

An object traveling through the circulation that can cause occlusion

52

What are the different types of an Embolus?

air

tumor

fat

bullets

foam

clot

53

What is hemodynamics?

blood flow characteristics

54

What is the Doppler angle?

The angle of the Doppler beam with respect to the angle of blood flow

Angle of Incidence

Angle theta q

55

What is the best Doppler angle?

0 o

56

What is the Optimal Doppler angle?

45o to 60o

57

What is the worst Doppler angle?

90o

58
card image

...

59

Explain angle correct?

card image

Visually adding a correction factor to the Doppler angle so that correct velocities can be calculated

60

What is Spectral Analysis?

card image
  • Plotting of returned Doppler signals
  • frequency shifts on the vertical axis
  • amplitude on the “Z” axis
  • Time on the horizontal axis
61

Explain velocity?

  • The speed of blood
  • Calculated from Doppler frequency shift & Doppler angle
  • velocity is proportional to frequency shift
  • Expressed as cm or m / second
62
card image

Where is peak systole?

card image

The highest point on the wave form

63
card image

Where is end diastole?

card image

The point just prior to the systolic upstroke

64

Beam Steering

card image
65

Depth penetration may be improved by _____________________ .

card image

Depth penetration may be improved by not steering the Doppler

66
card image

...

67
card image

Where is the waveform?

ICA

68
card image

Where is the waveform?

CCA

69
card image

Where is the waveform?

ECA

70
card image

Where is the waveform?

vertebral

71
card image

Where is the waveform?

subclavian

72

Hypoechoic / Anechoic

Dark or black areas on the image caused by objects with little or no reflectivity

73

Echodense/ Echogenic

Bright areas on the image caused by highly reflective material

74

Distal / Proximal Limits

The farthest and closest region that can be visualized

75

Plaque

card image

A swollen area of the lining of an artery formed by the deposition of lipids

76

Calcific Plaque

card image

Bright echogenic plaque which creates shadowing

77

Dense Plaque

Bright echogenic plaque which does not produce shadowing

78

Soft / Fibrous Plaque or Thrombus

card image

Plaque which produces echoes (not hypoechoic) but not as bright as dense or calcific plaque

79

Intimal thickening or Fatty streak

card image

Plaque that is along the wall of the vessel as a minimal amount

80

What is minimal degree of plaque?

10%

81

What is moderate degree of plaque?

60%

82

What is severe degree of plaque?

90%

83

What is Circumferential plaque?

Plaque along the entire lumen - all the way around

84

What is extensive plaque?

card image

Plaque along a lengthy segment of the artery

85

What is scattered plaque?

card image

Plaque found at several locations which are not connected

86

True Lumen

True Lumen is the original internal diameter of the vessel

87

Residual Lumen

Residual Lumen is the current internal diameter of the vessel

  • What’s left over after the plaque has taken over; where the blood flow is flowing
88

Homogenous plaque

less likely to ulcerate

  • Uniform in echo texture
89

Heterogeneous plaque

more likely to ulcerate

  • Nonuniform in echotexture
90

Smooth vs Irregular plaque

card image
  • Talking about the surface of the plaque and it’s probability of ulcerating
91

Ulcerative Plaque

card image

A scooped out appearance

shelf like projections

92

Occlusion

card image

Complete blockage

  • Best used with the terms probable & total
  • Complete filling of the vessel internal area with heterogeneous material
  • No blood flow
93

What must one do in calling an occlusion

sensitize the equipment before doing so

Decrease PRF

Increase color gain, use power Doppler

94

laminar flow

card image

Orderly

non-turbulent

95

Sharp flow

card image

Indicating a swift upstroke

Sharp peaks

96

Damped flow

card image

Slow upstroke

Rounded Peaks

97

Monophasic

card image

One upstroke within one cardiac cycle

98

Multiphasic

card image

Multiple upstrokes within one cardiac cycle

99
card image

Which is monophasic?

card image
100

Antegrade

card image

Flow in the direction that is expected from that specific vessel

101

Retrograde

card image

Flow that is reversed from the expected direction for that vessel

102

Characterization of flow disturbances

Turbulence

Spectral Broadening

Disturbed flow

Window Filling

Gross Turbulence

103

Aliasing

A Spectral Doppler Artifact of Pulsed Doppler systems

Spectral Doppler displays the peaks wrapped in the reverse direction

Color Doppler displays as a reversed color

104

Mosaic

card image

A mottled appearance caused by turbulent flow

105

Jet

card image

A localized area of higher flow through and after an area high grade stenosis

106

Diploplia

double vision

107

Drop attack

falling to the ground without other symptoms

108

Syncope

transient loss of consciousness

109

Bruits

abnormal flow sounds caused by turbulent patterns

110

Subclavian steal

abnormal flow direction into the subclavian from the vertebral artery caused by stenosis of the subclavian

  • Subclavian artery has a severe stenosis or occlusion
  • Vertebral artery must compensate for the reduction of flow
  • Becomes a collateral pathway to the extremity
  • RETROGRADE flow or abnormal flow present in the vertebral arter
111

What side does subclavian steal syndrome usually occur?

left

112

Amaurosis fugax

temporary partial or total blindness

113

Homonymous hemianopia

Blindness in the outer half of the visual field

114

Vertigo

difficulty in maintaining equilibrium

movement that is not real

115

Ataxia

inability to control gait or touch an article

116

Paresis

weakness or slight paralysis on one side of the body

117

Paresthesia

numbness or lack of feeling

118

Dysphasia

impaired speech

119

Aphasia

inability to speak

120

What is a Carotid body tumor?

A small mass of vascular tissue that adjoins the carotid sinus. It functions as a chemoreceptor sensitive to changes in oxygen tension of the blood and signals necessary changes in respiratory activity

121

Nonatherosclerotic lesions

Trauma

Fibromuscular Dysplasia (FMD)

  • dysplasia of the media with overgrowth of collagen
  • beadlike appearance on angiography
  • Seen in young women

Collagen vascular connective tissue disorders

122

Where does a Nonatherosclerotic lesions usually occur?

mid to distal

renal or carotid

123

What are the Mechanisms of disease?

  • Stenosis
  • Embolism
  • Thrombosis
  • Aneurysm
  • Nonatherosclerotic lesions
  • Carotid body tumor
124

What are the Risk Factors &
contributing diseases?

  • Diabetes mellitus
  • Hypertension
  • Smoking
  • Hyperlipidemia
125

What is a Cerebrovascular Accident (CVA)?

Produces a permanent neurological deficit

126

What is an acute CVA?

symptoms of sudden onset

unstable

127

What is a Stroke in evolution?

symptoms come and go

unstable

128

What is a Completed stroke?

No progression or resolution of the symptoms

stable

129

What are the symptoms of Vertebrobasilar Insufficiency?

  • Bilateral symptoms
  • Visual blurring
  • Paresthesia
  • Vertigo
  • Ataxia
  • Drop attacks
130

What is a Reversible Ischemic Neurologic Deficit (RIND)?

  • Lasts longer than a TIA
  • Deficits resolve in time
131

What is a TIA?

Transient Ischemic Attack - TIA

A fleeting neurological dysfunction without lasting effects

132

What are the symptoms of a TIA?

last minutes - hours

never more than 24 hours

sensory, motor, speech impairment, monocular visual disturbance

133

What is the Etiology of a TIA?

heart or carotid artery emboli

134

What is NASCET?

North American Symptomatic Carotid Endarterectomy Trial

135

What is ECET?

European Carotid Endarterectomy Trial (ECET)

136

What is ACAS?

Asymptomatic Carotid Atherosclerosis Trial (ACAS)

137

What was the endpoint for all 3 Carotid Endarterectomy Trials?

Reduction of hemispheric stroke & death

138

In the Carotid Endarterectomy Trials what showed long term benefits?

surgery in pt’s with >60 – 70% stenosis

for both symptomatic & asymptomatic over medical treatment

139

What are the key points of spectral broadening?

  • Spectral broadening is proportional to stenosis
  • Filled spectral window suggests >50% diameter
  • >70% stenosis has poor spectral border, high amplitude and low frequency
  • Spectral broadening may be the only sign of stenosis
140

What can we expect from post stenotic flow?

turbulent – nonlaminar

  • Although objective measurements have been created - - clinically spectral broadening is graded subjectively
141

What Factors cause abnormal Low PSV?

  • Collateralization
  • Low BP
  • Decreased cardiac output
142

What Factors cause abnormal High PSV?

Hypertension

143

Why do we calculate Systolic Velocity Ratio?

  • Physiological factors can change the absolute systolic velocities
  • By comparing the CCA to the ICA we remove the Physiological factors affect.
144

Why do we take the End Diastolic Velocity?

  • It becomes valuable in high grade stenosis
  • Will not show change below 50% stenosis
145

When does the PSV drop off?

Stenosis starts to exceed Approximately 90 %

146

What affects the PSV

length of the stenosis

  • A range of velocities are possible with variable stenosis - - - Precise velocity stenosis is not possible
147

What are the Cardinal Doppler Parameters?

Peak Systole

End Diastole

ICA/CCA Ratio

  • Critical that measurements are taken at the highest velocity
148

Explain the velocity increase in a stenosis.

The amount of velocity increase is small until the stenosis exceeds 50%

149

What is velocity proportional to?

Velocity will be proportional to the amount of stenosis.

By measuring the velocity we measure the stenosis

150

In vascular what is everything weighed by?

Everything that we do in Vascular is weighed by the velocity more so than the Bmode measurement

151

What happens when no cause of asymmetry can be found?

other modalities should be used to find the cause.

Major asymmetry between right & left should be a red flag

152

If the CCA is normal what do we say about the waveform?

Should be low resistance

153

If the Distal CCA is obstructed what happens to the waveform?

High resistance

ECA waveform

154

If the proximal CCA is obstructed what happens to the waveform?

Dampened Waveform

  • Best method of quantification is
155

What is the best method of Best method of quantification of the CCA

comparison with the contralateral side

156

CCA Pulsatility

  • Normally the Pre-stenotic Area
  • Stenosis can also occur at the CCA origin
  • CCA waveforms may appear pre-stenotic or post stenotic
157

What are the three critical areas?

  • Prestenotic Area
  • Stenotic Area
  • Post Stenotic Area