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Carotid

Protocol

Scan through each vessel prior to taking any images



This is a bilateral exam. The entire protocol will be performed on the right and left sides.

Structure Scan Plane Label - Images Stored
Identify Rt or Lt
and store
measurements
appropriately
Common Transverse CCA PROX Gray Scale
Carotid Artery CCA MID Gray Scale
CCA DIST Gray Scale
Bulb Transverse BULB Gray Scale
Bifurcation Transverse BIF Gray Scale
(ECA and ICA)
Common Sagittal CCA PROX Gray Scale
Carotid Artery Color Doppler
Proximal Color & Spectral Doppler - measure PSV and EDV
Common Sagittal CCA MID Gray Scale
Carotid Artery Color Doppler
Mid Color & Spectral Doppler- measure PSV and EDV
Common Sagittal CCA DISTAL Gray Scale - (1-2 cm from bulb)
Carotid Artery Gray Scale - (1-2 cm from bulb)
Distal *Zoom in on area with no plaque
Gray Scale - (1-2 cm from bulb)
* Zoom in on area with no plaque
*measure IMT of posterior wall
Color Doppler- (1-2 cm from bulb)
Color & Spectral Doppler - (1-2 cm from bulb) - measure PSV
and EDV
External Carotid Sagittal ECA Gray Scale
Artery Color Doppler
Color & Spectral Doppler-Proximal measure PSV and EDV
Internal Carotid Sagittal ICA PROX Gray Scale-Proximal
Artery Color Doppler-Proximal
Color & Spectral Doppler - measure PSV and EDV
ICA MID Color Doppler
Color & Spectral Doppler - measure PSV and EDV
ICA DISTAL Color Doppler - (most distal achievable)
Color & Spectral Doppler - (most distal achievable) -
measure PSV and EDV
Common Sagittal CCA Color Doppler
Carotid Artery
Vertebral Artery Sagittal VERT Color Doppler
Color & Spectral Doppler - measure PSV and EDV


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Carotid Protocol

Anatomical/Image Correlation

ECA

Dist Mid Prox


Prox

Mid CCA
Dist
ICA

Color Doppler

• Will vary with the presence/absence of pathology & curvature of the vessel
• Color images should relay the same information as your gray scale & spectral images
• Color box should be steered (angled) with the vessel direction
• Color in a normal vessel should be free of aliasing and extend to vessel walls
• Utilize preset color PRF (scale) and gain, and adjust according to the type of blood flow (velocities) being imaged
• If flow is normal and the color is outside the vessel wall or aliasing in center of vessel, slowly increase PRF
and/or decrease color gain until color is no longer outside the vessel wall or aliasing.
• If flow is normal and the color in the vessel is not filled in, slowly decrease PRF and/or increase color gain
until the color fills the vessel without aliasing or bleeding.
• Use power Doppler as needed to document flow in tortuous or deep segments of vessel.
• If complete occlusion is suspected, you must document the area with power Doppler to rule out any trickle flow.

Spectral Doppler

• Must use angle correct – Angle correct must be less than 60 degrees
• Gate (SV length) must be in center of vessel & small width.
• Use color Doppler appearance to aid in placement of gate for spectral interrogation. Your goal is to document the
highest velocities present.
• Set the PRF (scale) appropriately for the velocities imaged.
• Adjust the PRF (scale) to display a large waveform.
• Adjust the spectral gain so that there is no background noise on the spectral trace.
• Normal ICA waveform is low-resistive, with a brisk systolic acceleration, sharp systolic peak, and a clear spectral
window
• Normal ECA waveform is high-resistive, with a brisk systolic acceleration, sharp systolic peak, and a clear spectral
window
• Normal CCA waveform is relatively low-resistive (with slightly less diastolic flow than the ICA), with a brisk systolic
acceleration, sharp systolic peak, and a clear spectral window
• Elevated velocities with spectral broadening indicate a stenosis
• Record velocities in the stenotic area as well as approximately 2 cm prior to (prestenotic) and after (poststenotic)
the area of stenosis
• Stenosis is considered hemodynamically significant if the flow in stenotic area is twice the velocity of an area just
previous (prestenotic) to it
• Keep in mind that velocities will increase as blood moves through a curved portion of a normal vessel – if no
plaque is seen, Doppler just before or after the curve so that you do not make a make a normal vessel appear
abnormal



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Carotid Protocol

Tips

• For the ICA/CCA ratio, use the distal CCA velocity and the highest ICA velocity
• Intimal medial thickness (IMT) of the CCA should be measured in the distal CCA (approximately 1-2 cm before the
bulb) along the posterior wall
o Less than 10 mm is considered normal
• If retrograde flow is present in either vertebral artery, evaluate the subclavian artery on the affected side and
document with color and spectral Doppler
• Ways to differentiate ECA from ICA – It is extremely important that you do not misidentify these vessels!!
o ECA has a branch in the neck (the superior thyroid artery) – the first ICA branch is typically intracranial
o ECA is typically smaller
o ECA waveform is normally high resistive (although an ICA waveform will become high resistive with a
distal stenosis)
o Listen to the waveforms – they should sound different
o Be extra careful with a tortuous ICA that you do not “fall into” the ECA as you move distally
• Make sure that you scan as far distally as possible in the ICA

Criteria for ICA Stenosis (adapted from University of Washington and Society of Radiologists in Ultrasound)

Stenosis PSV ICA/CCA Ratio Spectral Characteristics
0% (normal) < 125 cm/s < 2.0 No spectral broadening
1% - 15% < 125 cm/s < 2.0 Spectral broadening in systolic deceleration
16% - 49% < 125 cm/s < 2.0 Spectral broadening throughout systole
50% - 79% 125 - 200 cm/s 2.0 – 4.0 Extensive spectral broadening
80% - 99% > 200 cm/s > 4.0 Extensive spectral broadening
100% (occluded) Absent N/A No flow signal in ICA; minimal diastolic flow or
reversed flow in ipsilateral CCA


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