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Premium member Presentation Transcript Peripheral vascular duplex case presentation : Peripheral vascular duplex case presentation Case 01 : Case 01 This patient had a recent cardiac catheterization with vascular access through the right femoral artery. One day after the catheterization a bruit was detected in the patient’s right groin. An ultrasound study was performed. Slide 3: Color Doppler image of the right groin . Description: This CDI demonstrates a typical color bruit artifact associated with tissue vibration. The color bruit artifact obscures underlying anatomical information. Spectral Doppler from above the vascular access site. : Spectral Doppler from above the vascular access site. Description: This spectral Doppler waveform was obtained from the femoral artery above the vascular access site. Spectral Doppler from below the vascular access site. : Spectral Doppler from below the vascular access site. Description: A spectral Doppler waveform obtained from the femoral artery below the vascular access site. diagnosis : diagnosis Color Doppler imaging will often demonstrate a color bruit artifact (as shown in Image 1) in the region of a previous arterial catheterization. A CDI image of the region using a higher CDI PRF (scale) may help to eliminate the CDI bruit artifact and permits identification of the precise site of the AVF communication (see Image 4). The use of the higher CDI PRF permits more accurate placement of a pulsed Doppler sample volume (see Image 5) to obtain a waveform typical of an AVF (i.e., a monophasic-continuous waveform with significantly elevated velocities throughout the cardiac cycle). CASE REFERENCESLiu JB, Merton DA, Mitchell DG, Needleman L, Kurtz AB, Goldberg BB: Color Doppler imaging of the iliofemoral region. Radiographics. 1990 10:403-412. Mitchell DG, Merton DA, Liu JB, Goldberg BB: Superficial masses with color flow Doppler imaging. J Clinical Ultrasound. 1991 19:555-560 Helvie MA, Rubin J. Evaluation of traumatic groin arteriovenous fistulas with duplex Doppler sonography. J Ultrasound Med 1989;8:21. Roubidoux MA, Hertzberg BS, Carroll BA, et al. Color flow and image-directed Doppler ultrasound evaluation of iatrogenic arteriovenous fistulas in the groin. J Clin Ultrasound 1990;18:463. Fellmeth BD, Roberts AC, Bookstein JJ, Freischlag JA, Forsythe JR, Buckner NK, Hye RJ. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology. 1991;178: 671–675 Coughlin BF, Paushter DM. Peripheral pseudoaneurysms: evaluation with duplex US. Radiology 1988;168:339. Helvie MA, Rubin JM, Silver TM, et al. The distinction between femoral artery pseudoaneurysms and other causes of groin masses: value of duplex Doppler sonography. AJR Am J Roentgenol 1988;150:1177. Fellmeth BD, Baron SB, Brown PR, et al. Repair of postcatheterization femoral pseudoaneurysms by color flow ultrasound guided compression. Am Heart J 1992;123:547. Polak JF, Donaldson MC, Whittemore AD, et al. Pulsatile masses surrounding vascular prostheses: real-time US color flow imaging. Radiology 1989;170:363. McCann RL, Schwartz LB, Pieper KS. Vascular complications of cardiac catheterization. J Vasc Surg 14:375, 1991. Kresowik TF, Khoury MD, Miller BV, et al. A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty. J Vasc Surg 1991;13:328 TECHNICAL DETAILSPhilips Medical Systems IU-22 scanner with L8-4 flat linear array probe FOLLOW UP Slide 7: DIFFERENTIAL DIAGNOSIS Arteriovenous fistula Arterial stenosis Pseudoaneurysm Arterial dissection Slide 8: FINAL DIAGNOSISArteriovenous fistulaDISCUSSIONArteriovenous fistulas (AVFs) can result when there is puncture of an artery and vein with a direct communication between the two injured vessels. A significant pressure gradient will result in a focal area of significantly increased velocity at the site of the AVF with flow directed from the artery to the vein. Color Doppler imaging of AVFs will often demonstrate a bruit artifact and/or a thrill may be palpable. Spectral Doppler analysis of the effected artery above the AVF will demonstrate a mono-phasic continuous waveform with elevated systolic and diastolic velocities. Flow in the injured artery distal to the AVF will generally have normal pulsatility. Spectral Doppler analysis of the effected vein central to the AVF will demonstrate “arterialized flow” with pulsations during systole and a lack of respiratory phasicity. Slide 9: Color Doppler imaging will often demonstrate a color bruit artifact (as shown in Image 1) in the region of a previous arterial catheterization. A CDI image of the region using a higher CDI PRF (scale) may help to eliminate the CDI bruit artifact and permits identification of the precise site of the AVF communication (see Image 4). The use of the higher CDI PRF permits more accurate placement of a pulsed Doppler sample volume (see Image 5) to obtain a waveform typical of an AVF (i.e., a monophasic-continuous waveform with significantly elevated velocities throughout the cardiac cycle). Slide 10: CASE REFERENCESLiu JB, Merton DA, Mitchell DG, Needleman L, Kurtz AB, Goldberg BB: Color Doppler imaging of the iliofemoral region. Radiographics. 1990 10:403-412. Mitchell DG, Merton DA, Liu JB, Goldberg BB: Superficial masses with color flow Doppler imaging. J Clinical Ultrasound. 1991 19:555-560 Helvie MA, Rubin J. Evaluation of traumatic groin arteriovenous fistulas with duplex Doppler sonography. J Ultrasound Med 1989;8:21. Roubidoux MA, Hertzberg BS, Carroll BA, et al. Color flow and image-directed Doppler ultrasound evaluation of iatrogenic arteriovenous fistulas in the groin. J Clin Ultrasound 1990;18:463. Fellmeth BD, Roberts AC, Bookstein JJ, Freischlag JA, Forsythe JR, Buckner NK, Hye RJ. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology. 1991;178: 671–675 Coughlin BF, Paushter DM. Peripheral pseudoaneurysms: evaluation with duplex US. Radiology 1988;168:339. Helvie MA, Rubin JM, Silver TM, et al. The distinction between femoral artery pseudoaneurysms and other causes of groin masses: value of duplex Doppler sonography. AJR Am J Roentgenol 1988;150:1177. Fellmeth BD, Baron SB, Brown PR, et al. Repair of postcatheterization femoral pseudoaneurysms by color flow ultrasound guided compression. Am Heart J 1992;123:547. Polak JF, Donaldson MC, Whittemore AD, et al. Pulsatile masses surrounding vascular prostheses: real-time US color flow imaging. Radiology 1989;170:363. McCann RL, Schwartz LB, Pieper KS. Vascular complications of cardiac catheterization. J Vasc Surg 14:375, 1991. Kresowik TF, Khoury MD, Miller BV, et al. A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty. J Vasc Surg 1991;13:328 TECHNICAL DETAILSPhilips Medical Systems IU-22 scanner with L8-4 flat linear array probe FOLLOW UP Case 02 : Case 02 A 52-year-old woman status-post cardiac catheterization presents with a pulsatile mass in the groin. Color Doppler scan of the pulsatile mass : Color Doppler scan of the pulsatile mass Description: A large vascular mass is noted with the characteristic Yin-Yan sign, that is typical of a pseudoaneurysm. Spectral waveform analysis at the neck of the vascular mass : Spectral waveform analysis at the neck of the vascular mass Description: The waveform at the neck of the mass reveals a typical to and fro pattern. Status post thromboplastin injection : Status post thromboplastin injection Description: Post thromboplastin injection, there is complete resolution of the vascular lesion. Slide 15: DIFFERENTIAL DIAGNOSISFemoral artery pseudoaneurysmFINAL DIAGNOSISFemoral artery pseudoaneurysmFOLLOW UPThe pseudoaneurysm was treated with thromboplastin injection which resulted in complete resolution. Case 03 : Case 03 A 50-year-old man status-post cardiac catheterization, now presents with a bruit in the right groin. Color flow Doppler evaluation of the groin : Color flow Doppler evaluation of the groin Description: Marked aliasing is noted in the artery and a stream of aliasing, suggestive of a fistula is noted between the femoral artery and vein. Slide 18: DIFFERENTIAL DIAGNOSISFemoral Arterio-venous fistulaFINAL DIAGNOSISFemoral Arterio-venous fistula Case 04 : Case 04 A 26-year-old woman with acute myeloid leukemia presents with a history of right femoral vein catheter insertion. She has had the catheter removed and presents for an ultrasound of the local region. Image of the femoral vein near the sapheno-femoral junction : Image of the femoral vein near the sapheno-femoral junction Description: An echogenic linear structure is seen adherent to the anterior wall of the common femoral vein. It exhibits posterior acoustic shadowing. This is suggestive of a retained catheter fragment. Transverse view of the femoral vein : Transverse view of the femoral vein Description: The retained catheter fragment is seen again in this image. Color Doppler image of the femoral vein : Color Doppler image of the femoral vein Description: The femoral vein fills with color except in the region of the catheter fragment. On real time ultrasound, this fragment was seen to oscillate with flow. The vein was compressible with no evidence of any thrombus Slide 23: DIFFERENTIAL DIAGNOSISRetained catheter fragmentFINAL DIAGNOSISRetained catheter fragmentFOLLOW UPA CT scan was performed which confirmed the presence of a retained catheter tip. Case 05 : Case 05 A 50 year old man had a cardiac catheterization via the right femoral artery five months prior and he now presents with an ipsilateral groin mass. A bruit could be heard over the mass. Transverse sonogram of the right groin. : Transverse sonogram of the right groin. Description: A large hypoechoic structure which shows posterior enhancement is seen in the right groin. Transverse color Doppler scan. : Transverse color Doppler scan. Description: The hypoechoic mass seen in the right groin completely fills with color showing turbulent flow with a yin-yang pattern. A large vessel is seen in very close proximity to this structure. Spectral analysis of the vascular mass. : Spectral analysis of the vascular mass. Description: Spectral Doppler indicates very turbulent flow within the mass. Color Doppler view. : Color Doppler view. Description: Two vessels are noted posterior to the vascular mass. One of them [a vein] shows a direct communication with the mass. Spectral analysis at the site of communication. : Spectral analysis at the site of communication. Description: An abnormal venous waveform [it is arterialized] is noted at the site of communication between the vein and the mass. Spectral Doppler of the common femoral vein. : Spectral Doppler of the common femoral vein. Description: A normal waveform is seen in the common femoral vein. Spectral analysis of the second vessel. : Spectral analysis of the second vessel. Description: A second vessel was also noted to be communicating with this mass. It demonstrated an arterial waveform [which is a low resistance flow] and the vessel appears to be a proximal branch of the right common femoral artery. Doppler of the proximal common femoral artery. : Doppler of the proximal common femoral artery. Description: A normal arterial waveform [high resistance] is noted. Slide 33: DIFFERENTIAL DIAGNOSISA large arteriovenous fistula between the common femoral artery and vein.FINAL DIAGNOSISAneurismal dilatation of an arteriovenous fistula between a branch of the right common femoral artery and the underlying femoral vein.DISCUSSIONVascular complications following femoral artery catheterization are on the rise due to wide usage of larger bore catheters and sheaths, longer duration of complex interventional procedures and extensive anticoagulation during the procedure. Iatrogenic pseudoaneurysms and arteriovenous [AV] fistulae of the femoral artery account for less than one percent and are among the most common vascular masses. The former is slightly more common and has been discussed in an earlier case. AV fistulae can be easily diagnosed with color Doppler ultrasound. According to Kurtz, et al, focal hemodynamic changes can be detected within about 1-2 cm of the actual communication and can be very striking. The site of AV fistulae often has a high velocity blood flow and this may result in turbulence and focal perivascular tissue vibration, resulting in an array of colors in the perivascular soft tissues. Spectral analysis of the artery supplying the fistula [as in this case] may show decreased resistance manifested as higher diastolic flow velocities and persistent forward flow throughout the cardiac cycle. This pandiastolic antegrade flow contrasts with the normally absent or reversed diastolic flow that occurs in most peripheral arteries. The communicating vein may also show a turbulent flow with an arterialized venous pattern. According to a few reports, AV fistulae with small shunt volume may spontaneously close. But in most cases surgical repair, endovascular repair via the placement of stents and coils and percutaneous ultrasound guided procedures such as compression therapy [for small AV fistulae] are some of the modes of treatment for the patients with AV fistulae. Once the fistula is repaired, monitoring by ultrasound can be easily carried out. Thus with the increasing incidence of post femoral artery catheterization fistulae, careful monitoring by non invasive modalities must be considered for early diagnosis and intervention. Case 06 : Case 06 An 85 year old male presented to the hospital with an acute intracranial bleed, thought to be secondary to amyloidosis. While in the hospital, he complained of swelling of the right leg. An ultrasound was performed to rule out venous thrombosis. The distal peripheral pulses were normal. Sagittal scan of the right popliteal region. : Sagittal scan of the right popliteal region. Description: Sagittal scan demonstrates an elongated solid mass with central hypoechoic component in the right popliteal fossa. The popliteal artery was not seen to be separate from this mass. The popliteal vein was normal. Transverse scan of the right popliteal artery. : Transverse scan of the right popliteal artery. Description: Transverse view showing the mildly echogenic mass with central hypoechoic component. Transverse color Doppler view. : Transverse color Doppler view. description: Transverse view demonstrates the central part of the mass to be vascular. Slide 38: Caption: Sagittal color Doppler scan. CASE PRESENTATION An 85 year old male presented to the hospital with an acute intracranial bleed, thought to be secondary to amyloidosis. While in the hospital, he complained of swelling of the right leg. An ultrasound was performed to rule out venous thrombosis. The distal peripheral pulses were normal. Description: Color Doppler demonstrating that the hypoechoic part fills with color and is the dilated proximal popliteal artery. Its distal part exiting the mass is normal. The popliteal vein [in red] appears to be compressed by the mass, but is patent. Spectral Doppler study. : Spectral Doppler study. Description: Spectral Doppler study through the vascular part of the mass demonstrates an arterial waveform. Slide 40: DIFFERENTIAL DIAGNOSISThrombosed right popliteal artery aneurysm, Baker’s cyst [but the color Doppler features effectively rule out this possibility], Pseudoaneurysm arising from the popliteal artery [but the popliteal artery is not seen seperate from the mass, so this most likely represents aneurysmal dilatation of the popliteal artery].FINAL DIAGNOSISPartially thrombosed right popliteal artery aneurysm.DISCUSSIONPopliteal artery aneurysms per se are not very common, but popliteal artery pseudoaneurysms are quite a common sequel to penetrating or blunt trauma, iatrogenic surgeries and procedures [rarely acupuncture] and adjacent bone tumors. Constant and repeated vascular wall trauma triggers the formation of the pseudoaneurysm. These vascular masses may present with pain and with palpable masses around the knee and may be pulsatile. If younger patients without a known history of trauma are diagnosed with popliteal artery aneurysms, underlying bone pathologies need to be ruled out as asymptomatic bone tumors may repeatedly irritate the popliteal artrey and present as popliteal artery aneurysms. Many patients with true aneurysms are asymptomatic and these may be detected incidentally, owing to their accessibility to palpation. Atherosclerosis likely plays some role in pathogenesis. Usually a popliteal artery is considered aneurysmal when the diameter is 1.2 cm or larger, a definitive aneurysm when it is 2 cm or greater or if it is more than 1.5 times the caliber of the proximal popliteal artery. Thrombosed aneurysms when symptomatic are usually found to be larger [3 cm or more]. Complications of these aneurysms include rupture, thromboemboli, and flexion deformities of the leg. Once thrombosis sets in, which is the most common complication, morbidity increases considerably. Lowell, et al in their study predicted aneurysm size greater than 2 cm, presence of thrombus and poor distal run-off as poor prognostic factors. The presence of these risk factors makes the patient an ideal candidate for an elective surgical treatment and prevents inadvertent amputations. Recent studies by Galland, et al have suggested 3 cm as the cut-off for the size of the aneurysm, after which intervention is needed. Real time ultrasound and color Doppler imaging are the initial non-invasive diagnostic modalities used to evaluate popliteal artery aneurysms. A dilated artery or a vascular mass arising from the artery is identified. Pseudoaneurysms can be seen connected to the main popliteal vessel via a neck or tract, the demonstration of which is pathognomonic for a pseudo aneurysm. If an aneurysm contains thrombus, echogenic material is seen within, which may partially or completely occlude the cavity. The hemo-dynamics can be studied by color Doppler, which may demonstrate swirling flow within the aneurysm or no color flow if it is completely occluded. The neck of the pseudoaneurysm may show a to- and –fro movement. Very importantly, the presence of thrombosis, distal run-off and collaterals can be assessed, which have prognostic value for the effectiveness and outcome of surgery. CT angiography, MR angiography and conventional angiography can all provide additional important preoperative information. CASE REFERENCES1.Lowell RC, et al. Popliteal artery aneurysms: the risk of nonoperative management. Ann Vasc Surg. 1994 Jan; 8(1): 14-23.2.Dawson I, et al. Atherosclerotic popliteal aneurysm. Brit J of Surg 84(3), March 1997: 293-99.3.Brzezinski T, et al. Supragenual popliteal artery pseudoaneursym in a patient with femoral bone exostosis. Case Rep Clin Pract Rev, 2003; 4(1): 43-45. 4.Atta HM, et al. Delayed presentation of popliteal artery pseudoaneurysm following blunt trauma. Am Surg. 1997 Jun; 63(6): 496-9. 5.Harman M, et al. Popliteal artery pseudoaneurysm: a rare complication of brucellosis. J Clin Ultrasound. 2004 Jan; 32(1): 33-6.6.Harder Y, et al. Popliteal aneurysm: diagnostic workup and results of surgical treatment. World J Surg. 2003 Jul; 27(7): 788-92.7.Galland, et al. Management of popliteal aneurysm. Brit J of Surg 2002, 89, 1382-85. 8.Ascher, et al. Small popliteal artery aneurysms: are they clinically significant? J Vasc Surg 2003 Apr; 37: 755-60. FOLLOW UPIn view of his acute intracranial bleed, this patient was not started on anticoagulants and was scheduled for a limb angiography followed by elective repair of the aneurysm upon stabilization. Case 07 : Case 07 Patient presenting with a mass in the groin two weeks post femoral artery catheterization. A bruit was heard over the puncture site. Serial ultrasound scans were performed. Transverse view of the right groin. : Transverse view of the right groin. Description: A large rounded heterogeneous area with a predominant hypoechoic component is seen in the right groin, in the region of the puncture site. Color Doppler view of the mass. : Color Doppler view of the mass. Description: The mass noted in the right groin shows two separate areas of flow peripherally. Color Doppler scan in the region of the mass. : Color Doppler scan in the region of the mass. Description: The mass is seen to be in close proximity to a vessel [the common femoral artery] and appears to arise from the artery. This suggests the possibility of a pseudoaneurysm with an associated hematoma. Spectral study of the mass. : Spectral study of the mass. escription: Spectral analysis of one of the areas showing prominent flow shows an arterial waveform with a component of reversed flow, in the region of the the neck of the pseudoaneurysm. Color Doppler study of the mass after two weeks. : Color Doppler study of the mass after two weeks. Description: The pseudoaneurysm appears to have spontaneously thrombosed. The two areas of flow which were seen in the earlier scan are not detected in the current study. Slide 47: DIFFERENTIAL DIAGNOSISPseudoaneurysm arising from the right common femoral artery.FINAL DIAGNOSISIatrogenic pseudoaneurysm with a hematoma arising from the common femoral artery with spontaneous thrombosis.DISCUSSIONThe incidence of vascular complications is on the rise due to the higher number of radiological procedures now performed via the femoral artery. The incidence of femoral artery pseudoaneurysm is around 1% following angiographies and interventional procedures. The other arterial complications that occur are arterial thrombosis, hematoma formation and arterivenous fistula. The longer duration of complex interventional procedures, usage of wide bore catheters and sheaths, and extensive anticoagulant therapy during the procedure are some of the risk factors responsible for the rising incidence of these pseudoaneurysms. By definition, a pseudoaneurysm is a pulsatile hematoma which communicates with an artery through a disruption in the arterial wall. Clinically a pseudoaneurysm presents as a pulsatile mass often with a bruit or palpable thrill and to-and-fro murmur. Ultrasound with Doppler plays a crucial role in the diagnosis of these iatrogenic vascular abnormalities. It demonstrates the cavity of the pseudoaneurysm, its size and communication with the femoral artery. A swirling pattern of blood flow may be seen in the pseudoaneurysm and the velocities can be measured in the pseudoaneurysm, its neck and the femoral artery. Documentation of the to-an-fro flow with spectral Doppler is essential to making the diagnosis. The size of the aneurysm may guide the physician as to whether a conservative approach or treatment is indicated. Kronzon, et al in his study reported that smaller aneurysms [< 2 cm] may usually be followed up; however depending on the size of the pseudoaneurysm a number of treatment options can be offered. A study by Toursarkissian, et al concluded that over 80% of stable pseudoaneurysms [pseudoaneurysms less than 3 cm in diameter were considered stable] and AV fistulae underwent spontaneous closure. Patients who had severe symptoms with an enlarging hematoma, groin infection, ischemia or nerve compression at the time of presentation were treated aggressively. Case 08 : Case 08 A 32 year old man presents with history of right sided claudication. He has numbness, tingling and decreased distal pulsations of the right lower extremity . He has no history of smoking. Sagittal color Doppler of the popliteal artery : Sagittal color Doppler of the popliteal artery Description: The popliteal artery shows normal dimensions. There is an area of soft tissue abnormality along the posterior wall of the popliteal artery and that area is devoid of color. The rest of the popliteal artery shows good wall to wall filling of color. Transverse color Doppler of the popliteal artery : Transverse color Doppler of the popliteal artery Description: The soft tissue mass is noted again in the popliteal artery. This mass shows good posterior enhancement suggesting that this mass is likely to be fluid filled. Incomplete filling of the popliteal artery by color is noted again. Sagittal scan of the popliteal artery : Sagittal scan of the popliteal artery Description: The abnormality is demonstrated again in this image. Spectral Doppler waveform in the proximal region : Spectral Doppler waveform in the proximal region Description: A normal arterial waveform with normal flow velocities [peak systolic velocity of 60 cm/sec] is noted in the right distal superficial femoral artery, proximal to the abnormal mass. Spectral Doppler waveform in the abnormal region : Spectral Doppler waveform in the abnormal region Description: The peak systolic velocity in the artery is very high in the area of the mass. It is approximately 158 cm/sec. MR angiogram image. : MR angiogram image. Description: The abnormal area shown in the previous ultrasound scans correspond to a cystic structure with fluid signal intensity. Slide 55: DIFFERENTIAL DIAGNOSISCystic adventitial disease of the popliteal artery, popliteal artery thrombus.FINAL DIAGNOSISCystic adventitial disease of the popliteal artery.DISCUSSIONCystic adventitial disease has been described as consisting of a collection of clear gelatinous material within an aberrant synovial type cyst located in the subadventitial plane of the wall of a major artery. These mucoid cysts may cause luminal compromise of the vessel and produce occlusive symptoms. This disease was first described in the external iliac artery in 1947 and in the popliteal artery in 1954. The popliteal artery is the most common site but the other sites in a descending order of occurrence include – Ilio-femoral artery, Brachial, radial and ulnar artery and Venous location - popliteal, lesser saphenous vein.The theories postulated for the etiology of the adventitial cyst include:1. Developmental theory – all the cysts develop in non-axial [appendicular] vessels. Therefore it is theororized that during limb bud development, mesenchymal cell rests from the adjacent joints migrate into these adjacent vessel walls. Later in life, these cells are responsible for secreting mucoid material resulting in the formation of a cystic mass within the vessel wall.2. Repeated trauma – microtrauma damages the adventitia, potentiates mucin production which results in the development of the cyst.3. Synovial origin – as some of these adventitial cysts have shown a communication with the adjacent joint capsule. 4. Ganglionic origin – this has been postulated because the histological appearance and the chemical composition of the adventitial cyst closely resembles that of a ganglion. Pathologically, the cysts in the vessel wall may be single or multiple; uni or multilocular and range in size from 1-8 cm. The cyst characteristically does not have a lining and does not communicate with the vessel lumen. Its fluid content is rich in hyaluronic acid.Clinical presentation – The patient is typically a young, non-smoking male who presents with intermittent claudication. The lesion causes dynamic exercise dependent flow inhibition. Imaging appearance – Ultrasound with color Doppler shows characteristic features that suggest the diagnosis:• An anechoic smooth walled mass seen in the wall of the popliteal artery. It shows good posterior enhancement suggesting that it is fluid filled. Sometimes, the contents of the cystic structure appear hypoechoic.• Usually a single large cyst is seen, which is eccentric in location. • Reduction in the diameter of the popliteal artery.• Color Doppler shows the reduction in vessel lumen, increased systolic and diastolic velocities in the narrowed segment of the artery and post stenotic elevations with flow turbulence. There might be distal flow reduction.The other modalities that can image this disease are CT and MRI, the latter being used more often. T2 weighted MRI images confirm the diagnosis and eliminate the need for conventional angiography. Arteriography shows a smooth-walled curvilinear narrowing. Differential diagnosis – the following may be considered:1. Aneurysm – the wall of the popliteal artery aneurysm is much more echogenic than the the wall of the adventitial cyst, if there is an associated thrombus, atherosclerosis or thickened and calcified intima.2. Synovial cyst- this is seen in the popliteal fossa and causes external compression of the artery.3. Popliteal artery entrapment syndrome -this occurs due to external compression of the artery as a result of anatomic deviation from its usual course or by compression from musculotendinous structures in the popliteal fossa.4. Popliteal arterial occlusive disease – in this case, lack of typical risk factors for atherosclerosis makes this diagnosis less likely. Management- There have been reports of spontaneous regression and spontaneous rupture of the cyst. However percutaneous US-guided cyst aspiration, surgical cyst evacuation and, if associated thrombosis of the artery, excision of the segment and by-pass graft are some of the treatment options available. CASE REFERENCES1. Brodmann M, Stark G, et al. Cystic adventitial degeneration of the popliteal artery-the diagnostic value of duplex sonography. Eur J Radiol. 2001 Jun; 38(3):209-12.2. Wright LB, Matchett WJ, et al. Popliteal artery disease: diagnosis and treatment. Radiographics. 2004 Mar-Apr; 24(2):467-79.3. Stautner A, Tsounis A, Stiegler H. Cystic adventitial degeneration. An important differential diagnosis in intermittent claudication. Vasa. 2001 May; 30(2):89-95.4. Levien LJ, Benn CA. Adventitial cystic disease: a unifying hypothesis. J Vasc Surg. 1998 Aug; 28(2):193-205.5. Lie JT, Jensen PL, Smith RE. Adventitial cystic disease of the lesser saphenous vein. Arch Pathol Lab Med. 1991 Sep; 115(9):946-8.6. Soots G. Cystic adventitial disease of the popliteal artery. J Mal Vasc. 1990; 15(2):179-81.7. Hildreth DH. Cystic adventitial disease of the common femoral artery. Am J Surg. 1975 Jul; 130(1):92-96.FOLLOW UPThis patient was operated upon and a cyst with one centimeter diameter was found in the mid popliteal artery that extended for a length of 2 cm. A cystotomy of the right popliteal artery was performed. The patient is currently doing well. Case 09 : Case 09 A 49 year old man status post motor vehicle accident and resultant left tibial and fibular fractures presents with left calf swelling for a week. He had been treated surgically for the fractures. An ultrasound of the left lower limb was performed. Extended field of view of the left calf : Extended field of view of the left calf Description: A large, hypoechoic, predominantly cystic mass is seen in the left calf corresponding to the region of swelling. Significant echoes are seen within the mass. Transverse color Doppler view of the area of calf swelling : Transverse color Doppler view of the area of calf swelling Description: No internal flow is recorded in the calf mass. Color Doppler proximal to the abnormal calf area : Color Doppler proximal to the abnormal calf area Description: A vessel is seen coursing in close proximity to the calf mass, which most likely based on its location, appears to be an arterial branch. The vessel superficial to it possibly represents the posterior tibial vein. Transverse color Doppler view in the abnormal area : Transverse color Doppler view in the abnormal area Description: A branch from the vessel that is coursing close to the calf mass exhibits apparent dilatation and appears to lead into the hypoechoic mass. Spectral Doppler analysis in the abnormal area : Spectral Doppler analysis in the abnormal area Description: A characteristic to and fro pattern is noted in the vessel proximal to the dilated branch that led to the mass. Follow up ultrasound scan : Follow up ultrasound scan Description: As marked by the arrows, there is an echogenic coil seen in the peroneal artery. The vessel superficial to it, which is the vein, appears normal. Follow up sagittal ultrasound scan : Follow up sagittal ultrasound scan Description: The peroneal artery,occluded by the echogenic coil, is noted again and shows no flow on color Doppler. Follow up scan demonstrating the calf mass : Follow up scan demonstrating the calf mass Description: The hematoma appears to have decreased in size following the coil occlusion procedure. The dilated arterial branch seen previously is not noted in this image. Spectral analysis of the occluded vessel : Spectral analysis of the occluded vessel Description: The to and fro pattern that was seen earlier is not seen now and the arterial branch is truly occluded. Slide 66: DIFFERENTIAL DIAGNOSISPeroneal or posterior tibial branch artery pseudoaneurysmFINAL DIAGNOSISPeroneal artery pseudoaneurysm with calf hematomaFOLLOW UPThis patient underwent an angiogram and subsequent successful vascular coil occlusion of the left peroneal artery pseudoaneurysm. Follow up Doppler scans showed occlusion of the vessel and a decrease in the size of the calf hematoma. Case 10 : Case 10 A 45 year old woman presents with redness and edema of her right calf. An ultrasound was performed. She has no other complaints other than some pain around the right hip joint. Sagittal view of a vessel in the groin : Sagittal view of a vessel in the groin Description: The vessel appears dilated and is filled with echogenic material suggestive of thrombus. The vessel was not compressible. Multiple views of the vessel in the groin : Multiple views of the vessel in the groin Description: The same vessel is noted again. The echogenic material is again seen distending the vessel. Sagittal and transverse views : Sagittal and transverse views Description: The same findings observed again. The vessel is the femoral vein. The femoral artery is seen adjacent to the vein in the transverse view. Color Doppler of the femoral vein : Color Doppler of the femoral vein Description: Some flow is noted in the thrombosed vein. Spectral analysis of the flow in thrombosed vein : Spectral analysis of the flow in thrombosed vein Description: The flow that was detected in the thrombosed vein shows an arterialized waveform. Spectral analysis of the flow in thrombosed vein : Spectral analysis of the flow in thrombosed vein Description: Multiple flow channels demonstrating arterialized flow pattern are detected in the thrombosed vein. Spectral analysis of the flow in thrombosed vein : Spectral analysis of the flow in thrombosed vein Description: The multiple flow channels showing arterialized flow are observed again in the thrombosed vein. Spectral analysis of the flow in thrombosed vein : Spectral analysis of the flow in thrombosed vein Description: A small channel of recanalized venous flow is noted. Spectral analysis of the flow in thrombosed vein : Spectral analysis of the flow in thrombosed vein Description: Similar finding is noted again with multiple areas of arterialized channels observed in the thrombosed vein. These findings are more in favor of a tumoral thrombus rather than a simple venous thrombosis. Axial CT scan of the groin : Axial CT scan of the groin Description: A large lobulated soft tissue mass is seen in close proximity to the right iliac crest. This was proven to be a sarcoma. Slide 78: DIFFERENTIAL DIAGNOSISTumor thrombus in the right femoral veinFINAL DIAGNOSISTumor thrombus in the right femoral veinDISCUSSIONThe presence of arterial flow inside a venous thrombus prompted the diagnosis of a tumor causing secondary venous thrombosis in this case. A search for the primary tumor lead to the discovery of the sarcoma involving the soft tissues around the right iliac crest. CASE 11 : CASE 11 Slide 80: A 39 year old woman presents with acute pain and redness of left lower limb. She was referred for a venous Doppler study with clinical diagnosis of deep vein thrombosis. Photograph of the symptomatic left lower limb : Photograph of the symptomatic left lower limb Description: The symptomatic lower limb demonstrates redness and swelling suggesting a clinical diagnosis of deep vein thrombosis. Sagittal scan of the popliteal fossa and calf : Sagittal scan of the popliteal fossa and calf Description: This scan shows evidence of fluid tracking between the deep fascia and the belly of gastrocnemius muscle. The fluid also is seen to have echoes. This suggests the presence of a Bakers cyst which has ruptured. Sagittal scan : Sagittal scan Description: The fluid is also seen communicating with the gastrocnemius –semi membranosus bursa. This is a boomerang shaped bursa and is comprised of a superficial portion, a deep portion and a neck. Color Doppler scan of the popliteal vessels : Color Doppler scan of the popliteal vessels Description: The popliteal artery and vein appear normal on color Doppler. The other vessels of the symptomatic lower limb were normal. Transverse scan in the upper calf region : Transverse scan in the upper calf region Description: The fluid containing boomerang shaped bursa is noted again in this image. Sagittal scan in the region of left popliteal fossa : Sagittal scan in the region of left popliteal fossa Description: This image demonstrates well the communication of the fluid with the bursa. Slide 87: DIFFERENTIAL DIAGNOSISRuptured Baker's cyst, deep venous thrombosis [clinical differential]FINAL DIAGNOSISRuptured Baker's cystDISCUSSIONThis case has been illustrated to demonstrate that a Baker`s cyst may rupture resulting in a clinical appearance of pseudothrombophlebitis. An ultrasound can easily distinguish between the two entities. CAROTID CASES : CAROTID CASES CAROTID CASE 01 : CAROTID CASE 01 This is a neck ultrasound performed in a 71-year-old man with a history of syncope, subdural hematoma and septicemia. Patient had a right IJV catheter. Transverse scan of the neck on the right side : Transverse scan of the neck on the right side Description: The right internal jugular vein appears expanded and shows the presence of an echogenic thrombus within. The vein was not compressible on real-time scan. Spectral waveform analysis of the right IJV- transverse view : Spectral waveform analysis of the right IJV- transverse view Description: No waveform can be recorded from the right IJV, confirming complete thrombosis. Spectral waveform analysis of the right IJV-sagittal view : Spectral waveform analysis of the right IJV-sagittal view No waveform can be recorded from the right IJV, confirming complete thrombosis. Spectral waveform analysis of the right carotid artery : Spectral waveform analysis of the right carotid artery Description: Normal arterial waveform is recorded from the right common carotid artery. Slide 94: DIFFERENTIAL DIAGNOSISAcute right internal jugular vein thrombosisFINAL DIAGNOSISAcute right internal jugular vein thrombosiss CAROTID CASE 02 : CAROTID CASE 02 This is a neck ultrasound performed in a 71-year-old man with a history of syncope, subdural hematoma and septicemia. Patient had a right IJV catheter. Transverse scan of the neck on the right side : Transverse scan of the neck on the right side Description: The right internal jugular vein appears expanded and shows the presence of an echogenic thrombus within. The vein was not compressible on real-time scan. Spectral waveform analysis of the right IJV- transverse view : Spectral waveform analysis of the right IJV- transverse view Description: No waveform can be recorded from the right IJV, confirming complete thrombosis. Spectral waveform analysis of the right IJV-sagittal view : Spectral waveform analysis of the right IJV-sagittal view Description: No waveform can be recorded from the right IJV, confirming complete thrombosis. Spectral waveform analysis of the right carotid artery : Spectral waveform analysis of the right carotid artery Description: Normal arterial waveform is recorded from the right common carotid artery. Slide 100: DIFFERENTIAL DIAGNOSISAcute right internal jugular vein thrombosisFINAL DIAGNOSISAcute right internal jugular vein thrombosiss CAROTID CASE 02 : CAROTID CASE 02 This is a duplex Doppler study in a patient with left carotid bruit. The patient has hypertension, elevated cholesterol, diabetes and history of radiation 8 years ago for laryngeal carcinoma. In order to get the quiz correct, you have to identify the 3 findings that are present in this study. Transverse scan of the left CCA : Transverse scan of the left CCA Description: There is an echogenic plaque present in the left CCA causing a reduction in the luminal diameter by at least 50%. Transverse scan of the right CCA : Transverse scan of the right CCA Description: The right CCA is completely occluded Sagittal scan of the right CC : Sagittal scan of the right CC Description: No flow is detected in the right CCA, which is occluded in its entire course. Scan at the level of the right carotid bifurcation : Scan at the level of the right carotid bifurcation Description: Both the right ECA and ICA show flow within their lumen, however flow is noted to be in the opposite direction. Spectral Doppler analysis of right ICA : Spectral Doppler analysis of right ICA Description: A normal arterial waveform is exhibited by the right ICA. Spectral Doppler analysis of right ECA : Spectral Doppler analysis of right ECA Description: There is reversal of flow in the right ECA; however a normal arterial waveform is noted. Slide 108: DIFFERENTIAL DIAGNOSIS1. Complete occlusion right common carotid artery2. Reversal of flow in the right ECA3. Plaque in the left common carotid arteryFINAL DIAGNOSIS1. Complete occlusion right common carotid artery2. Reversal of flow in the right ECA3. Plaque in the left common carotid arteryFOLLOW UPA CT angiogram was performed which confirmed the diagnosis. There was reversal of flow in the right ECA as the right ICA was fed by the right ECA. CAROTID CASE 03 : CAROTID CASE 03 This is the scan of the neck in a 65-year-old woman with complaints of audible bruits in the left ear and papilledema. She has a past history of left Sylvian fissure meningioma. Spectral waveforms of both common carotid arteries : Spectral waveforms of both common carotid arteries Description: The right CCA exhibits normal spectral waveform. The left CCA has a turbulent flow and exhibits high flow velocities [in the range of 180 cm/sec] Spectral waveforms of both external carotid arteries : Spectral waveforms of both external carotid arteries Description: The right ECA demonstrates a normal arterial waveform and flow velocity. The left ECA demonstrates a turbulent flow and elevated flow velocities. Spectral waveforms of both internal carotid arteries : Spectral waveforms of both internal carotid arteries Description: Both the internal carotid arteries demonstrate normal spectral waveforms with normal flow velocities. Spectral waveforms of both vertebral arteries : Spectral waveforms of both vertebral arteries Description: Both the vertebral arteries exhibit normal flow velocities. The left vertebral artery however demonstrates a turbulent flow. Spectral waveforms of both subclavian arteries : Spectral waveforms of both subclavian arteries Description: Both the subclavian arteries exhibit a normal spectral waveform with normal flow velocities. Slide 115: DIFFERENTIAL DIAGNOSISElevated velocities of the left CCA, left ECA suggest an indirect evidence of a left dural arterio-venous malformationFINAL DIAGNOSISLeft dural arterio-venous malformationFOLLOW UPAn angiogram and MRI was performed which showed a left dural arterio-venous malformation. CAROTID CASE 04 : CAROTID CASE 04 A 17 year old girl presents with a non-pulsatile neck mass of a hard consistency. An ultrasound of the neck was performed. Transverse image of the mass in the neck : Transverse image of the mass in the neck Description: There is a hypoechoic mass seen in the right side of the neck. It is seen in close proximity to the carotid artery. Oblique image of the mass : Oblique image of the mass Description: This oblique image also demonstrates the hypoechoic neck mass in close proximity to the right neck vessels. The mass per se shows no significant internal vascularity. Transverse image of the right sided neck mass : Transverse image of the right sided neck mass Description: The mass appears to displace the internal jugular vein and the carotid artery anteriorly. Oblique image of the right sided neck mass : Oblique image of the right sided neck mass Description: The heterogeneous mass is noted again. Slide 121: DIFFERENTIAL DIAGNOSISCarotid body tumor, an enlarged nodeFINAL DIAGNOSISCarotid body tumorDISCUSSIONCarotid body tumor may also be described as a chemodectoma, glomus tumor or a paraganglioma. It is a slow growing, benign tumor that is usually non-functioning. Aggressive behavior and malignant transformation of the tumor with peri-neural and vascular invasion is known to occur but is rare. Carotid body tumors are neuro-endocrine tumors that arise from the neural crest paraganglionic cells that are located at the level of the carotid bifurcation. These cells line the adventitia of the blood vessel. There may be a familial mode of inheritance. Many patients are asymptomatic or may present with laterally placed, slow-growing, soft masses in the neck. They may transmit the carotid pulsations and a bruit may be heard over the mass. Occasionally a patient may present with a hard and non-pulsatile mass. As the tumor enlarges, it may produce dysphagia/odynophagia or hoarseness. If the tumor is functioning, symptoms due to excessive production of catecholamines occur.Imaging features: Neck ultrasound with color Doppler is a reliable modality to image the entire extent of carotid body tumors. The following features are commonly recognized on ultrasound:1. A well-defined solid mass in the neck that may be unilateral or bilateral. 2. The mass is hypoechoic or may be weakly echogenic. Anechoic tubular channels representing small vessels may be seen within the mass. 3. The mass is seen classically in close proximity to the carotid bifurcation, widening the bifurcation and splaying the vessels. It may also appear to compress or encase the common, external and/or internal carotid vessels. 4. Color Doppler demonstrates significant internal vascularity within the mass in about 75% of all carotid body tumors. The feeders arise from the external carotid artery, although the internal carotid and the vertebral artery may also supply the carotid body tumor. 5.On spectral analysis, low resistance flow may be detected within the mass. Some of the atypical features that may be seen in a carotid body tumor include: 1. The characteristic splaying of the carotids may not be seen. 2. The mass may be hypovascular or avascular. The treatment of choice is surgical excision. A pre-operative biopsy is usually contraindicated [as these masses are typically very vascular and a biopsy may make adequate surgery difficult], and hence the importance of ultrasound in arriving at a diagnosis by demonstrating the classic location of the mass and its internal vascularity.CASE REFERENCES1. Niu L, Hao Y, et al. Sonographic diagnosis of carotid body tumor. Zhonghua Zhong Liu Za Zhi. 2002 Sep; 24(5):488-90. 2. Alkadhi H, et al. Evaluation of topography and vascularization of cervical paragangliomas by magnetic resonance imaging and color duplex sonography. Neuroradiology. 2002 Jan; 44(1):83-90. 3. Stoeckli SJ, et al. Evaluation of paragangliomas presenting as a cervical mass on color-coded Doppler sonography. Laryngoscope. 2002 Jan; 112(1):143-6. 4. Arslan H, Unal O, Kutluhan A, Sakarya ME. Power Doppler scanning in the diagnosis of carotid body tumors. J Ultrasound Med. 2000 Jun; 19(6):367-70. 5. Schreiber J, Mann W, Ringel K. The role of color duplex ultrasound in diagnosis and differential diagnosis of carotid body tumors. Laryngorhinootologie. 1996 Feb; 75(2):100-4. 6. Barry R, et al. Duplex Doppler investigation of suspected vascular lesions at the carotid bifurcation. Ann Vasc Surg. 1993 Mar; 7(2):140-4.FOLLOW UPAt surgery the tumor was seen to be arising from the carotid sheath, splaying the external and internal carotid artery. The vessel walls were intact and a biopsy confirmed the tumor to be a carotid body tumor. CAROTID CASE 05 : CAROTID CASE 05 A young man with previous history of motor vehicle accident one month prior with injury to the forehead now presents with a pulsatile swelling above his right eyebrow. Sagittal scan of the right side of the scalp. : Sagittal scan of the right side of the scalp. Description: An oval complex mass is seen in the soft tissues of the right forehead just above the brow in the region of the palpable mass. Sagittal image of the contralateral side. : Sagittal image of the contralateral side. Description: Normal soft tissue anatomy is noted on the contralateral side. Color Doppler image of the pulsatile mass. : Color Doppler image of the pulsatile mass. Description: The complex mass fills with color demonstrating a swirling color Doppler pattern. Color Doppler image of the mass. : Color Doppler image of the mass. Description: The right temporal artery is seen coursing anterior to the complex mass and appears to be the source of blood flow into the hematoma resulting in a pseudoaneurysm. Scan obtained after treatment. : Scan obtained after treatment. Description: Color Doppler image after thrombin injection shows thrombosis of the pseudoaneurysm. Slide 128: DIFFERENTIAL DIAGNOSISPost-traumatic pseudoaneurysm arising from a branch of the right superficial temporal artery.FINAL DIAGNOSISPost-traumatic pseudoaneurysm arising from a branch of the right superficial temporal artery.DISCUSSIONPseudoaneurysms of the superficial temporal artery can occur following blunt trauma to the head and various surgical procedures such as craniotomy or external drainage catheter placement. This diagnosis needs to be kept in mind while considering the differential for temporal fossa and forehead masses especially if there is a history of trauma. The clinical diagnosis is an easy one given the history and pulsatile nature of the mass. Occasional reports of these masses being non-pulsatile have been reported in which case they pose a clinical diagnostic dilemma. A bruit may also be heard. The anterior branch of the superficial temporal artery is particularly vulnerable to being impinged against the calvarium. This is so because it courses over the frontal osseous ridge and its course prevents it from being displaced in the event of trauma and hence making it more susceptible to traumatic injuries. It may not produce any major symptoms but treatment may be indicated to reduce the risk of hemorrhage from subsequent trauma, relieve headaches if it causes any and for cosmetic purposes. Neurological symptoms are hardly ever present. Ultrasound is diagnostic and shows a complex mass in the soft tissues in close proximity to the superficial temporal artery. The feeding artery can usually be identified. The differential diagnosis includes a hematoma, cyst, inflammatory lesion and vascular tumor. Color Doppler shows the characteristic findings of a pseudoaneurysm with a swirling flow and yin-yang pattern of color flow [bidirectional]. No flow would be visualized if it is thrombosed. A traumatic AV fistula may also coexist and can be diagnosed with ultrasound. Ultrasound is also now assuming a therapeutic role in treating these pseudoaneurysms. Thrombin injection to cause thrombosis of the pseudoaneurysm is fast becoming an acceptable mode of treatment with success rates nearing 100% according to many studies. However, one study reported seizures and ischemia of the scalp as a complication of this procedure and hence caution should be exerted while injecting thrombin. The other alternatives include radiological embolization and surgical repair. CASE REFERENCES1. Han K, Borah GL. Pseudoaneurysm of the anterior superficial temporal artery. Ann Plast Surg. 1996 Dec; 37(6):650-3.2. Angevine PD, et al. Pseudoaneurysms of the superficial temporal artery secondary to placement of external ventricular drainage catheters. Surg Neurol. 2002 Sep-Oct; 58(3-4):258-60.3. Weller CB, et al. Traumatic pseudoaneurysm of the superficial temporal artery: two cases. J Am Osteopath Assoc. 2001 May; 101(5):284-7.4. Cadamy AJ, et al. Traumatic pseudoaneurysms of the superficial temporal artery. Eur J Emerg Med. 2003 Sep; 10(3):236-7.5. Teh LG, Sieunarine K. Thrombin injection for repair of pseudoaneurysms: a case for caution. Australas Radiol. 2003 Mar; 47(1):64-6.6. Partap V, et al. US-guided percutaneous thrombin injection: a new method of repair of superficial temporal artery pseudoaneurysm. J Vasc Interv Radiol. 2000 Apr; 11(4):461-3.FOLLOW UPUnder ultrasound guidance, 100 units of thrombin was injected into the pseudoaneurysm cavity resulting in thrombus formation. No abnormal blood flow was documented following this therapeutic treatment. CAROTID CASE 06 : CAROTID CASE 06 A 57 year old woman presented with chronic headaches. When all investigations done on her returned normal, bilateral carotid Doppler study was performed. Sagittal image of the right carotid bulb and ICA : Sagittal image of the right carotid bulb and ICA Description: The right carotid bulb and the origin of the ICA appear normal. The mid portion of the ICA shows a String of Beads appearance. Sagittal image of the right ICA- mid portion. : Sagittal image of the right ICA- mid portion. Description: The mid portion of the right ICA shows multifocal areas of luminal narrowing alternating with dilatation -the classical String of Beads sign. Color Doppler image of the right ICA : Color Doppler image of the right ICA Description: Color Doppler suggests disturbed flow patterns in the area of luminal narrowing. Spectral waveform analysis of the proximal Rt. ICA : Spectral waveform analysis of the proximal Rt. ICA Description: The proximal part of the right ICA shows a normal arterial waveform with normal peak systolic and end diastolic velocities. Spectral waveform analysis of the Rt. ICA-mid part : Spectral waveform analysis of the Rt. ICA-mid part Description: An abnormal waveform is noted with spectral broadening and elevated peak systolic and end diastolic velocities. pectral waveform analysis of the distal Rt. ICA : pectral waveform analysis of the distal Rt. ICA Description: The abnormally elevated velocities still persist in the distal portion of the right ICA. Sagittal image of the left carotid bulb and ICA : Sagittal image of the left carotid bulb and ICA Description: The left carotid bulb and the origin of the ICA appear normal. The distal part of the ICA shows a relatively long segment of narrowing. Color Doppler image of the left ICA : Color Doppler image of the left ICA Description: The color Doppler image shows the segment of stenosis. A few small outpouchings are also noted in the distal part of the ICA. Spectral waveform analysis of the proximal Lt. ICA : Spectral waveform analysis of the proximal Lt. ICA Description: The proximal part of the left ICA shows a normal arterial waveform with normal peak systolic and end diastolic velocities. Spectral waveform analysis of the Lt. ICA-mid part : Spectral waveform analysis of the Lt. ICA-mid part Description: A normal arterial waveform is recorded. pectral waveform analysis of the distal Lt. ICA : pectral waveform analysis of the distal Lt. ICA Description: An abnormal waveform is noted with elevated peak systolic and end diastolic velocities. Slide 142: DIFFERENTIAL DIAGNOSISBilateral fibromuscular dysplasia of the carotid artery.FINAL DIAGNOSISBilateral fibromuscular dysplasia of the carotid artery.DISCUSSIONFibromuscular dysplasia [FMD] of the carotid artery is a non-atheromatous angiopathy that mostly affects middle aged woman. It affects the medium and large arteries, the most common being renal followed by carotid. This disease was first described in 1938 by Leadbetter and Burkland.This disease is bilateral in about 75% of the patients. Its etiology is unknown. The arteries other than renal and carotid to be involved are vertebral, lumbar, mesenteric, celiac, hepatic and iliac arteries. A deficiency of alpha-1 antitrypsin, mechanical trauma, genetic predisposition, ischemia of arterial wall and /or immunologic factors have been implicated in its pathogenesis. Types- Four histological types of FMD have been described:1. Intimal fibroplasia 2. Medial hyperplasia3. Perimedial dysplasia and 4. Medial fibroplasia – this is the commonest and occurs in 90% cases. It produces multiple areas of arterial stenosis. Patients often present with CNS symptoms of transient ischemic attacks, stroke, headache or vertigo. With renal involvement, patients present with reno-vascular hypertension. FMD is known to have an association with intracranial aneurysms, spontaneous dissections in the affected vessels, carotico-cavernous fistulas, thrombo-embolism and hemodynamic compromise of the distal circulation. Angiography is the preferred imaging modality; however ultrasound, CT angio or MR angio may be the initial imaging modality. Ultrasound features: According to the criteria by Arnig, etc. ultrasound criteria of FMD correspond to those of angiography and include-• Segmental String of Beads pattern with alternating areas of luminal narrowing and dilatation. • Localization in the distal part of internal carotid artery or vertebral artery.• Direct and/or indirect criteria of stenosis which may be unifocal or multifocal.A pattern that is noted in atypical fibromuscular dysplasia is involvement of only one wall of the affected segment which may show a diverticulum-like smooth outpouching.Differential diagnosis:1. Takayasu’s arteritis – this is an inflammatory angiopathy that involves the aorta and other major branches of the aorta. Stenosis is much more commonly seen than aneurysms.Management- If the patient has symptomatic carotid artery disease, surgery in the form of arterial resection and graft placement or percutaneous transluminal angioplasty with or without stenting may be performed. If the FMD is asymptomatic it can be managed conservatively.CASE REFERENCES1. Kochan Jeffery. FMD (Carotid Artery) http://www.emedicine.com/radio/topic280.htm2. Tan AK, et al. Ischaemic stroke from cerebral embolism in cephalic FMD. Ann Acad Med Singapore. 1995 Nov; 24(6):891-4. 3. Arning C, Grzyska U. Color Doppler imaging of cervicocephalic FMD. Cardiovasc Ultrasound. 2004 Jul 20; 2(1):7. 4. Wesen CA, Elliott BM. FMD of the carotid arteries. Am J Surg. 1986 Apr; 151(4):448-51. 5. Krzanowski M. Fibromuscular dysplasia of the internal carotid artery as a cause of transient cerebral ischemia episodes. Pol Arch Med Wewn. 1997; 98(12):546-50. 6. Winter R, et al. Color-coded duplex ultrasound imaging of intimal FMD of the carotid artery. Nervenarzt. 1998 Oct; 69(10):905-8. 7. Cloft HJ, et al. J Neurosurg. 1998 Mar; 88(3):436-40. 8. Mettinger KL, Ericson K. FMD and the brain. I. Stroke. 1982; 13(1):46.FOLLOW UPA CT angiography was performed which confirmed the diagnosis of bilateral fibromuscular dysplasia affecting the carotid artery without significant luminal stenoses. Imaging of major abdominal vessels revealed no abnormality. The patient was offered regular surveillance. CAROTID CASE 07 : CAROTID CASE 07 This is a patient who gave a prior clinical history of left carotid endarterectomy. His current complaints involve loss of vision in the left eye. Spectral waveform analysis of left ICA origin : Spectral waveform analysis of left ICA origin Description: No flow is recorded in the left internal carotid artery. Spectral waveforms of left CCA and vertebral artery : Spectral waveforms of left CCA and vertebral artery Description: The left CCA demonstrates an externalized waveform. The vertebral artery waveform is normal. Color Doppler image at left carotid bifurcatio : Color Doppler image at left carotid bifurcatio Description: An echogenic thrombus is seen occluding the left internal carotid artery. The left common carotid artery appears normal. Spectral waveforms of right ECA and vertebral artery : Spectral waveforms of right ECA and vertebral artery Description: The right external carotid artery and the vertebral artery reveal normal arterial waveforms. [Contrast it with the waveform seen in image 2] Spectral waveforms of right common and ICA : Spectral waveforms of right common and ICA Description: Normal arterial waveforms are noted in the right common and internal carotid artery. Spectral waveforms of the left MCA and ACA : Spectral waveforms of the left MCA and ACA escription: Both these arteries show flow towards the transducer. This indicates normal flow in the MCA, but indicates reversal of flow in the ACA as the normal ACA flow is away from the probe. Spectral waveforms of left MCA and ACA : Spectral waveforms of left MCA and ACA Description: The left anterior cerebral artery shows reversed flow. Waveforms of both ACA from left temporal window : Waveforms of both ACA from left temporal window Description: There is increased flow in the right anterior cerebral artery towards the transducer and flow reversal in the left anterior cerebral artery. Spectral waveforms of both the MCAs : Spectral waveforms of both the MCAs Description: This is the right and left middle cerebral arteries sampled from the left temporal window. Both show flow in the opposite direction which is normal. Slide 153: DIFFERENTIAL DIAGNOSISComplete left internal carotid artery occlusionFINAL DIAGNOSISComplete left ICA occlusion with changes in the ipsilateral anterior circulation as described.DISCUSSIONThe transcranial Doppler findings in cases of ICA occlusion can help to identify concurrent intracranial occlusions or compensatory changes that occur in the anterior circulation. The spectrum of findings include - reversed flow in the ipsilateral ACA, - reduced flow velocity in the ipsilateral MCA and - elevated flow velocity in the contralateral ACA [all these findings are noted here]. A few other findings that have been noted in literature include reversed flow in ipsilateral ophthalmic artery and concurrent absent flow in the arteries of the anterior circulation. CASE REFERENCES1. Demchuk A., Christou I., Wein T., Felberg R., et al. Specific Transcranial Doppler Flow Findings Related to the Presence and Site of Arterial Occlusion. Stroke. 2000; 31:140. CAROTID CASE 08 : CAROTID CASE 08 A 60 year old woman presented for sudden visual loss in the right eye, exophthalmos, chemosis and proptosis. Functional ophthalmologic examination revealed immobility of the right eye, weak pupillary reaction to the light, right axial exophthalmos and right proptosis. Gray-scale ultrasound of the right orbit : Gray-scale ultrasound of the right orbit Description: Normal appearance of the right eye bulb is seen. A unilocular anechoic elongated mass is seen on the posterior aspect of the eye bulb, extending to the tip of the orbit and producing dislocation of the optic nerve. Color Doppler of the right orbit : Color Doppler of the right orbit Description: High velocity bi-directional flow with marked turbulence is noted within the retroocular mass. On pulsed Doppler, arterial pulsatile flow was noted within the mass which exhibited low impedance, indicative of a large arterio-venous communication. Color Doppler of the anterior pole of the orbit : Color Doppler of the anterior pole of the orbit Description: Abnormal dilated tortuous vessels with craniofugal flow were noted on the superior wall of the anterior pole of the orbit. Craniofugal flow with maximal velocity above 2m/sec was recorded at the orbit tip. Axial T2 weighted MR image : Axial T2 weighted MR image Description: A mass at the level of the right carotid siphon in the parasellar region and located along the course of the carotid is seen indenting the sphenoid sinus and the sella. A retroocular mass continuous with vessels in the anterior pole of orbit is seen. MRA 3D non-contrast TOF protocol for arteries : MRA 3D non-contrast TOF protocol for arteries Description: The mass at the carotid siphon is well observed and it is seen to continue with the internal carotid artery. The vessels in the anterior pole of the orbit are not visualized. MRA 3D non-contrast TOF examination for veins : MRA 3D non-contrast TOF examination for veins Description: Both the dilated anterior orbital vessels and the mass of the right carotid siphon are depicted. Slide 161: DIFFERENTIAL DIAGNOSISCarotid-cavernous fistula - suggested by the presence of enlarged orbital vessels with low impedance flow Hypervascular ocular tumor - arterial feeders and enlarged draining veins are usually absentArteriovenous malformationCavernous orbital angiomaFINAL DIAGNOSISMRI confirmed the final diagnosis to be a carotid-cavernous fistula and a right carotid artery aneurysm.DISCUSSIONCarotid cavernous fistulae represent a direct communication between the arterial flow of the carotid siphon and the venous compartment of the cavernous sinus 1, 2, 3. Carotid cavernous fistulae can be classified by:1. Etiology: as traumatic or spontaneous. The traumatic fistulae occur more frequently, (75% of cases), appearing after car accidents or after endovascular therapy. Spontaneous fistulae usually result from a ruptured carotid aneurysm, in collagen vascular disease, atherosclerotic disease, hypertension, or at childbirth 3. 2. Flow: high or low flow3. Anatomy: direct and indirect, according to the arterial branch involved (internal carotid artery [ICA], meningeal branches of the internal carotid artery or external carotid artery [ECA]). Barrow’s classification 4 divides the carotid cavernous fistulae into four types:• Type A: a fistula between the intracavernous segment of ICA and the cavernous sinus• Type B: a shunt between the dural branch of the ICA and the cavernous sinus• Type C: a shunt between the meningeal branch of the ECA and the cavernous sinus• Type D: a shunt between branches of the ICA and the ECA and the cavernous sinus 1, 4. According to this classification our case is included in type A. Young men are more likely to develop traumatic fistulae than others, presumably due to the increased incidence of trauma in this patient group. Postmenopausal women are prone to develop spontaneous dural carotid cavernous fistulae 4. The association between a carotid cavernous fistula and an ICA aneurysm, secondary to a cranio-cerebral trauma or caused by a connective tissue defect, is a rare occurrence 1. Our patient did not have a history of cranio-cerebral trauma. For this reason, we assume that her condition was caused by a connective tissue defect. On Doppler ultrasound, the alteration of ICA hemodynamics (decreased resistence index and increased blood flow volume) is considered an indirect arterial sign of carotid cavernous fistula. Indirect venous signs are represented by enlargment of the superior ophthalmic vein, with reversed or bidirectional flow associated with a systolic component and reversed flow in the supraorbitar vein, with high flow velocity and low resistance. Thickening and dislocation of the optic nerve and sometimes, superior ophthalmic vein thrombosis may also be observed. Ultrasound may be useful in avoiding angiography, the latter being the golden standard. Ultrasonography can also be used in the follow-up of patients with slow venous flow or patients treated by embolization 1, 5, 6, 7, 8, 9. In our case, orbital ultrasound revealed the bidirectional, turbulent flow with systolic component in the right superior ophtalmic vein and optic nerve dislocation. Yu-Wei Chen, et al. proposed the division of Barrow’s type A carotid cavernous fistulae in two categories, based on the ultrasonographic features: type I direct carotid cavernous fistula and type II carotid cavernous fistula with aneurysm. Based on this classification, our case belongs to type A II. The natural evolution of carotid cavernous fistulae includes increasing proptosis, cranial nerve palsies, loss of vision (due to central retinal vein occlusion or glaucoma), epistaxis and intracranial or subarachnoid hemorrhage. Carotid cavernous fistula can be effectively treated by occluding the fistula with transarterially deployable detachable balloons with preservation of the internal carotid artery. In the event that the balloon cannot be fed through the fistula via a transarterial approach, detachable platinum coils are often deployed electrolytically via a transarterial route 4, 10, 11, 12. CASE REFERENCES1. Zu-Wei Chen, et al. Carotid and Transcranial color-coded duplex sonography in the different types of Carotid-Cavernous Fistula. Stroke; 2000; 331:701-706. 2. Bahar Zanik, et al. JUM; 2003; 22: 1107-1110. 3. Koenigsberg, Robert A. CC Fistula, eMedicine World Medical Library, December 2002. 4. Barrow DL, et al. J Neurosurg 1985 Feb; 62(2): 248-56. 5. Kilic T, et al. Acta Neurochir (Wien). 2001 Dec; 143(12): 1257-64. 6. Dudea S.M, et al. Revista Romana de Ultrasonografie, vol. 4, Nr. 3-4, 2002.7. Dudea S. M. Ultrasonografie vascularã. Bucureºti, Editura Medicalã 2004, 541-548. 8. Spector RH. Am J Ophthalmol 1991 Jan 15; 111(1): 77-83. 9. Chynpransky M, et al. Csek Slov Oftalmol. 1997; 53(2): 112-6. 10. Wetzel SG, et al. AJR 2000 May; 174(5): 1293-5. 11. Wadlington VR, Terry JB. Crit Care Clin 1999 Oct; 15(4): 831-54. 12. Onizuca M, et al. Neurol Med Chir. 2003; 43(10): 477-82.TECHNICAL DETAILSWe used a Medison Kretz Sonoace 8800 ultrasound machine with a 7.5-10 MHz linear transducer and a 1 Tesla General Electric machine for the MRI. Carotid case 09 : Carotid case 09 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.