Collateral circulation in carotid and vertebral territory: Color Doppler analysis

Transcription

1 Collateral circulation in carotid and vertebral territory: Color Doppler analysis Poster No.: C-0069 Congress: ECR 2015 Type: Educational Exhibit Authors: L. C. C. Chierighini, P. C. Francolin, M. C. Chammas, G. G. Cerri, A. P. Romualdo; São Paulo/BR Keywords: Vascular, Head and neck, Ultrasound physics, Ultrasound, Ultrasound-Colour Doppler, Ultrasound-Spectral Doppler, Recanalisation, Technical aspects, Diagnostic procedure, Education and training, Obstruction / Occlusion, Image registration DOI: /ecr2015/C-0069 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 32

2 Learning objectives To demonstrate the collateral circulation pathways that can be observed in pathological studies at color Doppler in territories of carotid and vertebral arteries. Page 2 of 32

3 Images for this section: Fig. 2: Pulsed and color Doppler image showing the inversion of the left external carotid artery flow to fill the internal carotid artery in a patient with left common carotid artery obstruction due arteritis. Peter Francolin Page 3 of 32

4 Background The arterial system is responsible for the transport of oxygenated blood to organs and tissues. Some pathological conditions can interrupt or reduce the blood supply, for breach of continuity of this system. We can enumerate the trauma, the arteritis and atherosclerosis. Atherosclerosis, in particular, can lead to progressive reduction of the volume of blood to an organ, and is associated with widely known and proven risk factors, such as hypertension, obesity, diabetes, hypercholesterolemia, sedentary lifestyle, chronic kidney disease, smoking, among others. The body has defense mechanisms to maintain the blood supply. We can enumerate the resistance fall of peripheral bed (by vasodilation), compensatory increase in blood pressure, increased heart rate, compensatory arterial enlargement and formation of collateral circulation. For collateral circulation mean a set of arteries that provide an alternative flow circuit, in order to perfuse ischemic or hypoxic bed due to stenosis or occlusion of a core network circulation. This mechanism occurs throughout the human body, as the need for each organ and tissue. Color Doppler is an excellent tool for screening of stenoses or occlusions in the territory of the carotid and vertebral arteries. On pathologic examination, several ways of collateral blood circulation can be established in order to maintain normal cerebral perfusion. Some of collateral circulation pathways can be observed by color Doppler sonography and should be recognized by the examiner. In obstructive disease of the internal carotid artery (ICA), the collateral circulation is important to maintain adequate cerebral perfusion. The primary collateral via the circle of Willis is, with the possibility to redistribute the flow from the ICA through the contralateral anterior communicating artery or arteries from vertebrobasilar via the posterior communicating artery. Secondary collaterals routes include the external carotid artery by anastomosis of eleptomeníngeas artery (not assigned to ultrasound) and ophthalmic artery on the surface of the brain. Page 4 of 32

5 Images for this section: Fig. 3: B-mode image showing obstruction of the left common carotid artery and atherosclerotic plaques in the bulb and emergence of the internal and external carotid arteries Peter Francolin Page 5 of 32

6 Fig. 4: Color Doppler mapping showing stenosis of the left common carotid artery in a patient with Takayasu arteritis. Observe the limited common carotid wall thickening, determining threadlike flow. peter Francolin Page 6 of 32

7 Fig. 5: Pulsed and color Doppler mapping showing complete obstruction of the left common carotid artery Peter Francolin Page 7 of 32

8 Findings and procedure details The reversal of blood flow can be observed at color and spectral Doppler, which is a hemodynamically significant signal of stenosis or occlusion in proximal arterial bed. The arterial refilling occurs by collateral circulation, and the antegrade flow to distal bed, since the arrival of collateral artery and retrograde flow to proximal segments from collateral artery. The degree of stenosis of the carotid and vertebral arteries is directly estimated based on color Doppler measurements of flow velocities in the vascular lumen. However, the signal which characterizes the establishment of collateral circulation involving the cervical region is the inversion of the direction of flow. There is no speed criteria to discriminate if a flow is related to a collateral circulation. The tardus-parvus pattern is associated with post-stenotic flow, but not pathognomonic of collateral circulation. In this paper we will present the main collateral circulation pathways that can be observed in the carotid-vertebral system studies using high frequency linear transducer (9-15 MHz). The following collateral circulation pathways are known: 1-BRANCHES OF EXTERNAL CAROTID ARTERY: The external carotid artery runs ascending path after the bifurcation of the common carotid artery and has an average of eight branches that supply the face and neck structures: superior thyroid artery, lingual artery, facial artery, occipital artery, maxillary artery and the superficial temporal artery. The branches of the external carotid artery establish collateral circulation especially with branches of thyroid-cervical trunk, vertebral arteries and arteries of the brain circulation (not visible on ultrasound). All of these arteries can participate in collateral circulation in cases of occlusion of the common carotid artery and the internal carotid artery. Occurs refilling the external carotid artery through its branches, especially: - Reversing the direction of flow of the external carotid artery by its branches, refilling the internal carotid artery by stenosis or occlusion of the common carotid artery. 2- BRANCHES OF INTERNAL CAROTID ARTERY: the ICA does not emit branches up into the skull, where its branches supplying the brain. These branches are hardly studied by ultrasound, due to sound access, except for the ophthalmic artery. In case of occlusion of the proximal internal carotid artery, ophthalmic artery inversion can submit its flow direction in an attempt to refill the distal internal carotid artery, through the filler present angular artery, temporal branch, branch of the external carotid artery. It may also occur reversal of the distal internal carotid artery through the circle of Willis to Page 8 of 32

9 replenish the ophthalmic artery in occlusions of the proximal internal carotid artery, but this phenomenon can not be observed with high frequency linear transducers. 3- BRANCHES OF SUBCLAVIAN ARTERY: The arteries of the thyroid-cervical trunk can refill, retrograde, external carotid arteries, in attempting to establish collateral circulation to the system of internal carotid artery. The vertebral arteries may also reverse its direction of flow, to refill the subclavian artery or brachiocephalic trunk, when there is a proximal occlusion or stenosis. This condition is known as "subclavian steal", and their progressive establishment determines changes in wave morphology, according to the procedure. ARTERIES MEASUREMENTS: Can be observed by ultrasonography, with high frequency linear transducer and present reversal of flow direction, the following arteries: 1. External Carotid Artery 2. Facial Artery 3. Temporal Artery 4. Superior Thyroid Artery 5. Inferior Thyroid Artery 6. Maxillary Artery 7. Vertebral Artery 8. Ophthalmic Artery Page 9 of 32

10 Images for this section: Fig. 6: Color Doppler mapping showing reversal flow of the left external carotid artery (blue) to refill the left internal carotid artery (red) in patients with occlusion of the left common carotid artery. Peter Francolin Page 10 of 32

11 Fig. 7: Pulsed Doppler image showing complete obstruction of the left common carotid artery (same as the previous). Peter Francolin Page 11 of 32

12 Fig. 8: Pulsed Doppler image showing low impedance flow in the internal carotid artery after refilling thereof, by collateral circulation Peter Francolin Page 12 of 32

13 Fig. 9: Two images with color Doppler mapping of the previous case. The left, cross section of the common carotid artery showing no flow in its lumen. The right cross section showing external and internal carotid pervious flow with color Doppler Peter Francolin Page 13 of 32

14 Fig. 17: Color Doppler mapping showing reversal flow of the left superior thyroid artery to refill the left external carotid artery in a patient with obstruction of the left common carotid and left subclavian arteries peter Francolin Page 14 of 32

15 Fig. 10: Color Doppler mapping showing no flow in the right internal carotid artery in a patient with complete obstruction peter Francolin Page 15 of 32

16 Fig. 11: Color and pulsed Doppler mapping showing refill the right external carotid artery by your side peter Francolin Page 16 of 32

17 Fig. 12: Color Doppler mapping showing lumen thinning in the left common carotid artery due to Takayasu's arteritis peter Francolin Page 17 of 32

18 Fig. 13: Color Doppler mapping showing reversal flow of the left external carotid artery (blue) to fill the internal carotid artery (red) in patient with obstruction of the left common carotid artery due arteritis Peter Francolin Page 18 of 32

19 Fig. 14: Color and pulsed Doppler mapping showing normal flow and direction in the left ophthalmic artery Peter Francolin Page 19 of 32

20 Fig. 15: Color and pulsed Doppler mapping showing reversal flow of the right ophthalmic artery peter Francolin Page 20 of 32

21 Fig. 16: Color Doppler mapping showing reversal flow of the right ophthalmic artery Peter Francolin Page 21 of 32

22 Fig. 18: Color and pulsed Doppler mapping showing complete reversal of the flow of the right vertebral artery in a patient with subclavian steal Peter Francolin Page 22 of 32

23 Fig. 19: Color and pulsed Doppler mapping showing post stenotic flow pattern in the left subclavian artery after its completion through the vertebral artery. Patient had occlusion of the proximal segment of this artery peter Francolin Page 23 of 32

24 Fig. 20: Pulsed Doppler mapping showing change in the left vertebral artery wave morphology, featuring subclavian steal installation (patient with stenosis of the proximal left subclavian artery) Peter Francolin Page 24 of 32

25 Fig. 21: Color Doppler mapping showing occlusion of the left subclavian artery (arrow) associated with reversal of the left vertebral artery (blue) with filling of the distal left subclavian artery (red). Peter Francolin Page 25 of 32

26 Fig. 22: Color Doppler mapping performed with low-frequency convex transducer showing occlusion of the left subclavian artery (arrow) associated with inversion of the left vertebral artery (blue) filling the distal left subclavian artery (red) peter Francolin Page 26 of 32

27 Fig. 23: Color and pulsed Doppler mapping showing change in the left vertebral artery wave morphology, featuring subclavian steal installation (patient with stenosis of the proximal left subclavian artery). Note that there is no retrograde flow established at this stage. Peter Francolin Page 27 of 32

28 Fig. 24: Color and pulsed Doppler mapping in patient with subclavian steal installation. Performed maneuver the cuff, and occluded the left brachial artery. Observe the wave morphology tending to normal (positive maneuver) Peter Francolin Page 28 of 32

29 Fig. 25: Color and pulsed Doppler mapping in patient with subclavian steal installation (same as the previous). Performed decompression of the cuff, intensifying the subclavian steal by relational hyperemia in the upper limb (positive maneuver). Peter Francolin Page 29 of 32

30 Conclusion The knowledge of the main cranial collateral circulation pathways can assist the understanding and recognition of stenoses, occlusions and flow compensation pathways in patients with atherosclerosis and arteritis processes. Page 30 of 32

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32 9- Quantitative Vascular Measurements in Arterial Occlusive Disease. Hideki O, MD, Kei T, MD, Hiroya R, MD, Masahiro T, MD, Takayuki Y, MD, Akihiro S, MD, Shuichi H, MD, Tadashi I, MD, Shoki T, MD. RadioGraphics 2005; 25: Imaging Diagnosis of Subclavian Steal Syndrome Secondary to Takayasu Arteritis Affecting a Left-Side Subclavian Artery. Ernesto RV, Pedro HM, Sandra OP, Irma EA, Veronica EC, Gustavo. CCArchives of Medical Research 34 (2003) Noninvasive Vascular Laboratory for Evaluation of Peripheral Arterial Occlusive Disease: Part I-Hemodynamic Principles and Tools of the Trade. Steven CR, MD. JVIR 2000; 11: Variability of Doppler US Measurements along the Common Carotid Artery: Effects on Estimates of Internal Carotid Arterial Stenosis in Patients with Angiographically Proved Disease. Vivian S. Lee, Barbara S. Hertzberg, Michael J. Workman, Tony P. Smith, Mark A. Kliewer, David M. DeLong, Barbara A. Carroll Radiology, 2000, Vol.214: , /radiology r00fe25387 r-latin;mso-bidi-font-family:"times New Roman"; mso-bidi-theme-font:minorbidi;mso-ansi-language:en-us;mso-fareast-language: EN-US;mso-bidi-language:ARSA'>Radiology, 2000, Vol.214: , /radiology r00fe25387 Page 32 of 32