Carotid Disease - HD

Key Question on Imaging Modalities

The key question is, should I stop here
or did we really need to contrast an ultrasound
for this kind of disease?
Every start and look at the MRI image
and CT image, we see immediately that it's very difficult
to beat this modality.
On the MRI, we see very nice the sub clain stenosis
of meta stenosis and the internal artery stenosis.
Also here in the city we see the seno as external artery,
the internal artery.
Could we be better or not? That's the key question.
In this case, if you think about stenosis, we have
to make a decision.
Does this patient really have good nose
and we have to discuss it.
What will be the best treatment?
Should be stent surgery
or if there's a occlusion nor treatment.
There's a couple of new options.
The most used option in this case is contra ultrasound.

Contrast Ultrasound Examination Process

Normally examination will start
with the gray skin cord artery followed by color.
Doppler look about the scanning angle,
how the change the curing of the vessel.
And now I repeat the examination
by using the contrast science or the sun setting.
Did you have seen this stenosis here before in the ler?
I think most of us will probably haven't seen it,
but you see a probably very bright weather
without overriding artifact
and without limitation to the scanning angle.
It's up to you whether you would like to have
just the contrast,
the pure contrast signal on the right side
or whether you would like to mix it
with some background information.
I personally prefer the background information
because then we have some anomic landmarks on the image.
For the current art notice it's essential
to know it really is S noses.
How high is the degree of S nose or maybe a pseudo occlusion
or occlusion?
Everybody see this high degree of S noses
with a soft plug on the ventral part of the
current artery and also on the dorsal part
we are always seen by using the color offset.
There is a high velocity inside
and if we measure
inside we got velocity about nearly five meter,
this mean over 90%.
So everybody confirm this is a high degree
of the nose which should be treated so
will be there any benefit If we now
inject additional contrast,
I would like to show you this case.
So your contrast arrived, you see the pres zoonotic flow,
intra stenotic flow and the post flow without artifacts.
Did you have seen the vascularization of the plug? No.
Probably. For future you have to think about whether
culation of a plaque is indicator
to make the decision whether patient maybe should get under
earlier another surgery or not.
And you'll see probably complete extent of the kind of
nose as I've shown you here.
Look again, you can see small bubbles here which appear on
the wall under the stem graft
and under the plug on this part
of the plug there's no cross uptake
and if you magnify it, you can see
where the entrance is it from the vessel,
some arrive from the vessel
but also couple of bubbles arrive from the wall.

Evaluating Occlusion

On the other side you have
to exclude whether it's really an occlusion or not.
So the question in this patient was,
does this patient has good occlusion of the ICA?
Yes or no? Take your time and look carefully.
The next case I will ask you again,
I'll show you the card image.
Is there any flow on the ICA? Yes or not?
If there will no flow,
our vascular surgeon will not treat the patient
because then the vascular is occluded.
But if there will be a minimal flow, this patient has to
risk to develop stroke again.
So what's your opinion? Is there a flow or not?
It's course. This is a point where you normally stopped
during a normal examination
and now you have to make a decision will be there any need
for contrast or not.
I repeat the examination, this is the excellent artery.
You'll see exa cord artery
and here you see a pseudo occlusion of the ICA.
And if you ask me how long is this pseudo occlusion,
you'll see the complete extent of the pseudo occlusion
and now we find pretty good indication
to treat the pseudo occlusion because you could prove it.

Minimal Flow Detection

Now on the other side, very similar case
by using the LAR we could see a nice flow on the extra
current artery,
but in the internal air,
current artery we could not see any flow.
By using the power doppler we get the semi results.
And finally if we use the contrast we say
there is a minimal flow here
but the rest of the vessel is complete occluded.
But keep in mind that you also have to shift the probe in
that degree because if the flow will be on the right side
of the vessel wall, you will miss it.
If you're in the center of the vessel
after making the decision, you have to think about
what will be the best therapy for your option.
Should it be open surgery or should it be stenting?
This patient undergo of the open surgery,
you'll see the dilatation
of the bowel here you'll see some plaque here.
The question is how does it look Now by using BLA
or powder blood, probably see more of the bulb,
but if we now compare this by using the contrast setting,
you'll see pretty good the complete extent
of the ball without the artifact.
We see the soft plaque here, see the external cord artery,
internal cord artery, the soft plaque here on the wall,
but overall the results are fine without limitation
as we seen by car doppler.

Post-Surgical Complications: Hematoma

On the other side, there also could be appearing
complications like hematoma
and the question is, is this now
a hematoma which have got an active bleeding, yes or no?
Therefore we just look again in the plane we see just
adjacent to the called hematoma
and probably it's very difficult to rule out by using the
LER to say that this hematoma doesn't show
any contrast uptake.
If you repeat the examination,
you see the patient has some problem with the heart
because contrast arrive
for the first time in the gro vein
instead of the cold artery.
Then you see the hematoma is complete black,
it doesn't show any uptake
and of course you have got a window up to two minutes
and you have time to scan the complete hematoma,
still black, never look later,
still black saw no active bleeding
and this also means no treatment of this hematoma.

In-Stent Stenosis Detection

You think about standing, you have also think, keep in mind
that sometimes patient suffer from instant stenosis.
So if you look carefully at the stand graft
and I ask you to this see stenosis,
you will probably say you need the car dola,
I give you the BLA and power dola
and you have asked yourself again, did you see stenosis?
Finally I measure the velocity.
Unfortunately we have got a velocity about 250 centimeters.
The problem is we didn't know what was in the past,
how high was the velocity?
So did you see a stenosis now or not?
If you are only reliable on the velocity, there seems
to be a stenosis but it's not clearly visible
by using the LAR or powder plus settings.
If a repeat no examination by contrast you see
that here something is missing.
Normally contrast should fill the complete stent graft.
Also, if you look at the axi plan, about 50%
of the perfused lumen doesn't show any contrast uptake here.
If I magnify the image again
and scan the complete stand graft, you'll see
how much lumen is missing.
With contrast uptake.
That means that patient has got at least 40% of the lumen
is a stenosis inside
and these kind of stenosis are very easy
to miss if we don't use the c.
The contant ultrasound,
this patient has got a ICA osis on the right side we see it
also on the MRI examination.
This patient was treated with a stent graft
and the question is does the patient has got no an incense
osis or not by using the Kala?
It seems to be that here we have some high velocity
because to the changing of the color
and the question is, is this now a high
degree of S noses or not?
If we measure inside,
we got the velocity about four centimeters,
the very high degree of stenosis
and if we repeat the examination by contrast we see
that this patient has got an instant stenosis on the ventral
part and also the dorsal part of stand graft.
These are not, these are artifact from the calcification
of the corded wall.
It can also measure the distance between the perfuse lumen
and the original lumen
and can make a correlation in order
to measure the diameter stenosis.
The question is could we see it by ct?
Same examination, same patient underwent ct.
I think it's big, big challenge
to say whether this patient has got an
instant the noses or not.
And finally the patient undergo intervention
and it confirmed the instant the noses,
the patient received another stent
and afterwards we see it looks better.
But I'm not sure whether there was really a
successful treatment.

Dissection Cases

Dissection are not so often, often they will ask you,
what about perfused lumen?
Is there any perfused lumen?
Are there two perfused lumen or not?
If you look carefully at the gray scale,
you'll see that here.
Something wrong on the dorsal part of the
of the call it wall here.
The question is, is this now a hypertrophy of the IMA
or is this just a dissection?
By using the colar?
It seems to be that here something is wrong in the vessel.
The same is confirmed by using the power doppler
and also if you look very carefully at the power plant,
it seems to be that here is some flow.
The next step we inject contrast.
You see dissection of the cor artery as the syn tear
and if you wait you'll see there the contrast is uptake.
You'll see the complete extent of this, the earth
of the dissection with a true lumen and with a false lumen.

Rare Cases: Fistula, Pseudoaneurysm, and Aneurysm

Here sometimes we have
also rare cases like fistula or aneurysm
or tumors in the current arteries.
This was an old woman which undergo central line excess.
Unfortunate was very difficult
and afterwards the patient have some
problems with the heart.
So the question is, was fistula yes or not?
If you look at the gray scale, it seems
to be he has a connection between the corded artery
and the ular vein.
By using the color block we see already this kind
of analyzing very similar
as I shown you this in the audio in the IVC.
And if you now compare this, you'll see immediately
what was the angle for the intervention.
It was not the perfect angle.
Probably in order
to avoid this complication they should have gone other
access to the gro vein.
What about this patient?
This patient also undergo in the uh,
central line excess unfortunately was also a little bit d
difficult and we should prove whether it was a fist or not.
But we see just between the ular vein
and OID artery hematoma,
we also see some flow in the hematoma.
Another question is in pseudo aneurysm or not.
So we could see that the bubbles appear very fast,
much faster in comparison to the ular vein.
In the beginning there was no connection
between the pseudo aneurysm and the ular vein.
So this is a kind of pseudo aneurysm
after intervention of the ular vein
because a puncture also the cord artery
and afterwards they have got this hematoma
with a pseudonym also.
Here you see the complete extent of this aneurysm
and this was also treated under vascular surgeon.
Aneurysm of the cord artery are rare.
You have to exclude what is the diameter of the aneurysm
and does this aneurysm have thrombotic changes.
This is the external cord artery.
This is the inter cord artery.
This is a common current artery.
By using the OR powder blur we see most of the part
of the aneurysm, but the question is
how much thrombotic changes are in the aneurysm.
Also here, if we inject contrast,
you'll see the complete extent of this aneurysm
with internal cord artery, ex cord art.
We see some branch here
and if you shift the probe, you see about 30%
of this aneurysm have thrombotic changes in the wall.

Carotid Body Tumor Case

This was a young man which sent to our department
because his outstanding doctor said there was a high
suspicion of an aneurysm of the common court artery.
But remember these are really cases,
so maybe it's a thrombotic changes at the wall here.
But if we look at the color blood,
we could also detect some flow inside.
So you can say probably this is not an aneurysm, it seems
to be just a tumor.
If you look at the perfusion,
you see this tumor have got an immediately contrast uptake
like the called artery.
So was the called artery body tumor with just adjacent
to the bulb here.
Here's the ification between the iac,
the external cord artery and the internal IAC art artery.
If you have got it's called body tumor, they compress the
with and you have to think about treatment.
You see the perfusion of the tumor.
But if you look at the perfusion by using the contrast,
you see how much this tumor show
very fast can uptake in comparison to the normal tissue.
Lot of vascularization.
There's a couple of options how to treat these body tumors.
Either you do an embolization with onyx
or the patient have to go under vascular surgeon.
In this case, we make a decision that we would like
to treat it with onyx,
so we use a protection system in order to avoid a stroke
and afterwards we inject in the tumor some onyx glue
after treatment, no perfusion of the tumor.
And of course we also would like to prove it
by using the gray scale.
You see the white dots here inside that the glue.
By using the curler, we couldn't see any weather inside.
Finally repeat the examination with the contrast setting
and also he can say this was a successful treatment
because this cold body tumor doesn't show
any perfusion anymore.
So you could immediately see the results of your prevent
by using this kind of technique.

Conclusion and Indications

So we have seen that a couple of indication for the vascular
for the guidance recommendation was called art stenosis
or follow up after called stenting.
There seems to be some advantage regarding dissection
or complication after vascular invention.
I don't speak so much about cold plugs because
otherwise only another half hour in this session.
So thanks for attention.