NON-ATHEROSCLEROTIC PATHOLOGY OF THE CAROTID ARTERIES
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1 NON-ATHEROSCLEROTIC PATHOLOGY OF THE CAROTID ARTERIES Leslie M. Scoutt, MD, FACR Professor of Diagnostic Radiology & Surgery Vice Chair, Dept of Radiology & Biomedical Imaging Chief, Ultrasound Section Medical Director, Non-Invasive Vascular Lab Yale University School of Medicine
2 DISCLOSURE Educational consultant for Philips HealthCare
3 OUTLINE Discuss the diagnostic US features of nonatherosclerotic vascular pathology of the carotid arteries Dissections Arterio-venous fistulae Pseudoaneurysms Vasculitis
4 CCA DISSECTION Usu result of extension from a dissection in the aortic arch Older pts Relatively asymptomatic neck or chest pain Often stabilize Rx may not be required Only ~ 3-7% assoc with stroke
5 CCA DISSECTION
6 CCA DISSECTION Look as proximally as possible when dissection extends from thoracic aorta May not involve both CCAs
7
8 CCA DISSECTION Mural hematoma or thrombosed false lumen
9
10 POST-TRAUMATIC CAROTID ARTERY DISSECTION Thrombosed False Lumen
11 ICA DISSECTION Young to middle aged pts M = F Clinical presentation: headache neck or facial pain hemispheric symptoms cranial nerve palsy Horner syndrome stroke
12 ICA DISSECTION Usu occur secondary to trauma or spontaneous dissection implies weakness in vessel wall Usu start at skull base and dissect down towards bifurcation More likely to have a mural hematoma and less likely to have an intimal flap Harder to see on US better evaluated on MR, CT or angio More likely to result in stroke
13 ICA DISSECTION Common cause of stroke in young pts Others causes: cardiac disease tumor vasculitis
14 ICA DISSECTION US findings: NORMAL (remember, it starts at the skull base)
15 ICA DISSECTION US findings: NORMAL (remember, it starts at the skull base) ICA occlusion in young pt
16
17 ICA DISSECTION US findings: NORMAL (remember, it starts at the skull base) ICA occlusion in young pt high resistance ICA waveform with no stenosis or plaque at bulb
18 US findings: ICA DISSECTION
19
20 ICA SKULL BASE RT LT
21 ICA LT SKULL BASE
22 ICA DISSECTION US findings: NORMAL (remember, it starts at the skull base) ICA occlusion in young pt high resistance ICA waveform in young pt with no stenosis or plaque at bulb smooth tapering ICA stenosis in young pt homogeneous, hypoechoic thick wall (intramural hematoma) no evidence of atherosclerosis, calcified plaque PSV
23 ICA DISSECTION Smooth, tapering stenosis, thick hypoechoic wall
24 ICA DISSECTION Can confirm presence of blood in vessel wall w/ MR or CT High signal intensity intramural hematoma
25 ICA DISSECTION Rare to see dissection flap in ICA
26 ARTERIO-VENOUS FISTULA Arteriovenous connection usually btwn CCA and IJV Etiology: trauma (blunt or penetrating), including iatrogenic attempted neck line or needle placement post surgical erosion in pts w/ malignancy or s/p XRT congenital
27 ARTERIO-VENOUS FISTULA Presentation: hematoma bruit noise or ringing in ear palpable thrill CHF distended IJV Rx: carotid stent or surgery
28 SOFT TISSUE BRUIT Increased velocity & pressure changes cause vibration of surrounding soft tissues color mosaic What to do? gain scale, PRF wall filter image in diastole
29
30 CCA-IJ FISTULA
31 CAROTID ARTERY PSA Etiology: trauma (usu direct puncture) infection malignancy (erosion) weakened arterial wall XRT, dissection, FMD, Ehlers-Danlos & Marfan syndromes Risk: rupture Rx: carotid stent or surgery
32 CAROTID ARTERY PSA US findings: cystic mass yin-yang appearance of swirling blood flow to & fro flow in neck towards PSA in systole away from PSA in diastole depends on size of neck
33 28 yr old IVDU w/ Neck Pain CCA PSA, largely thrombosed
34 28 yr old IVDU w/ Neck Pain To & fro flow pattern in neck
35 62 yo Female 5 yrs s/p CEA Presents w/ TIA & Abnl CT Scan
36 62 yo Female 5 yrs s/p CEA Presents w/ TIA & Abnl CT Scan
37 PSA ARISING FROM ICA ABOVE CEA SITE
38 PSA ARISING FROM ICA ABOVE CEA SITE Attempted stent placement Coiled & non-retrievable Converted to open OR
39 POST-OP COMPLICATIONS: CEA 67 yo woman presents w/ enlarging, hard palpable neck mass for 1 yr 3 yrs s/p Lt CEA
40 POST-OP COMPLICATIONS: CEA PSA: Swirling or yin-yang pattern of blood flow
41 FIBROMUSCULAR DYSPLASIA Arterial dxs of unknown etiology: α-1-antitrypsin deficiency? ischemic, hormonal, mechanical stress Incidence % Most common in yr old women 3:1 F to M ratio
42 FIBROMUSCULAR DYSPLASIA Medium to large arteries: Renal arteries most commonly involved ICA 2 nd most common 1/3 have renal artery involvement 10-20% incidence of spontaneous carotid dissections 30% have intracranial aneurysms May present with TIA, hemorrhage, stroke, asymptomatic
43 FIBROMUSCULAR DYSPLASIA Beaded appearance of ICA power Doppler best edge resolution 65% bilateral long segment narrow lumen
44 FIBROMUSCULAR DYSPLASIA May see PSV due to stenosis However, PSV may be artificially low 2 0 to long length of stenosis, multiple tandem lesions
45 TAKAYASU ARTERITIS Aortic arch syndrome, pulseless disease Presentation: absent pulses in upper extremities Inflammatory disease of unknown etiology: granulomatous inflammation 1 0 effects the wall of the aorta and major branches results in arterial stenosis, thrombosis and aneurysms
46 TAKAYASU ARTERITIS yrs 8-9 times more common in females Higher incidence in Asian women, uncommon in North America most common cause of renovascular hypertension in India Rx: steroids, chemotherapy
47 Courtesy Dr Ed Grant
48 TAKAYASU ARTERITIS Courtesy Dr Ed Grant
49 TAKAYASU ARTERITIS
50 TAKAYASU ARTERITIS
51 RADIATION ARTERITIS
52 RADIATION ARTERITIS Delayed effect of cervical XRT Hodgkin disease squamous cell head and neck CA Pathology: accelerated atherosclerosis, inflammatory changes, fibrosis Surrounding scar tissue/soft tissue fibrosis can also contribute to CCA stenosis or occlusion
53 RADIATION ARTERITIS 30-40% occurrence rate after high dose cervical XRT Takes 5-10 yrs to develop Stroke rate ~7% after cervical XRT ulcerate, occlude, PSA, rupture Rx: stent Should pts be screened?
54 RADIATION ARTERITIS
55 TEMPORAL ARTERITIS Giant cell arteritis chronic systemic inflammatory arteritis Women over 50 yrs old Presentation: headache, visual abnormalities, systemic myalgias and arthralgias Superficial temporal artery may be painful on physical exam
56 TEMPORAL ARTERITIS Primarily involves superficial temporal artery (branch of ECA) can involve any medium to large artery US findings: wall thickening, narrowing of lumen, surrounding hypoechoic halo May stroke Dx: bx of superficial temporal artery Rx: steroids
57 TEMPORAL ARTERITIS Diastolic flow in ECA >> CCA
58 CONCLUSIONS Don t forget to look for non-atherosclerosis related pathology of the carotid arteries during the Doppler US exam US is an excellent way to diagnose CCA dissections, AFVs, PSAs not as accurate for ICA or VA dissections may need angio for complete evaluation or to guide stent placement
59 CONCLUSIONS Limited role in the evaluation of vasculitis But, consider vasculitis, dissection or XRT arteritis in pts with long segment smooth wall thickening, esp in CCA Consider screening pts 5 to 10 yrs s/p cervical XRT
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