Noninvasive Cerebrovascular Diagnosis

184 Pages·2010·40.143 MB·English

by  Ali F. AbuRahma MD, FACS, FRCS, RVT, RPVI (auth.), Ali F. AbuRahma MD, FACS, FRCS, RVT, RPVI, John J. Bergan MD, FACS, Hon FRCS (eds.)

Noninvasive Cerebrovascular Diagnosis

·
Ali F. AbuRahma John J. Bergan
Editors
Noninvasive
Cerebrovascular
Diagnosis
Editors
AliF.AbuRahma,MD,FACS,FRCS,RVT,RPVI JohnJ.Bergan,MD,FACS,HonFRCS
Professor UCSDSchoolofMedicine
Chief,Vascular/EndovascularSurgery LaJolla,CA
DepartmentofSurgery USA
RobertC.ByrdHealthSciencesCenter
WestVirginiaUniversity
and
MedicalDirector,VascularLaboratory
Co-Director,VascularCenterofExcellence
CharlestonAreaMedicalCenter
Charleston,WV,USA
ISBN978-1-84882-956-5 e-ISBN978-1-84882-957-2
DOI10.1007/978-1-84882-957-2
SpringerLondonDordrechtHeidelbergNewYork
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(cid:2)c Springer-VerlagLondonLimited2010
Firstpublishedin2000aspartofNoninvasiveVascularDiagnosis,editedbyAliF.AbuRahmaandJohnJ.Bergan,
ISBN1-85233-128-3,2ndeditionpublished2007,ISBN978-1-84628-446-5
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Table of Contents

1. Overview of Cerebrovascular Disease................................................................................................................................ 1
Ali F. AbuRahma

2. Overview of Various Noninvasive Cerebrovascular Techniques...................................................................................... 19
Ali F. AbuRahma

3. Duplex Scanning of the Carotid Arteries........................................................................................................................... 29
Ali F. AbuRahma and Kimberly S. Jarrett

4. The Role of Color Duplex Scanning in Diagnosing Diseases of the Aortic Arch Branches
and Carotid Arteries ......................................................................................................................................................... 59
Clifford T. Araki, Bruce L. Mintz, and Robert W. Hobson II

5. Vertebral Artery Ultrasonography .................................................................................................................................... 67
Marc Ribo and Andrei V. Alexandrov

6. Transcranial Doppler Sonography …................................................................................................................................ 73
Marc Ribo and Andrei V. Alexandrov

7. Ultrasonic Characterization of Carotid Plaques ................................................................................................................ 97
Andrew N. Nicolaides, Maura Griffin, Stavros K. Kakkos, George Geroulakos,
Efthyvoulos Kyriacou, and Niki Georgiou

8. Carotid Plaque Echolucency Measured by Grayscale Median Identifies Patients
at Increased Risk of Stroke during Carotid Stenting. The Imaging in Carotid Angioplasty
and Risk of Stroke Study ................................................................................................................................................ 119
A. Froio, G. Deleo, C. Piazzoni, V. Camesasca, A. Liloia, M. Lavitrano, and G. M. Biasi

9. Duplex Ultrasound in the Diagnosis of Temporal Arteritis ............................................................................................ 125
George H. Meier and Courtney Nelms

10. Duplex Ultrasound Velocity Criteria for Carotid Stenting Patients ............................................................................... 131
Brajesh K. Lal and Robert W. Hobson II

11. Use of Transcranial Doppler in Monitoring Patients during Carotid Artery Stenting..................................................... 137
Mark C. Bates

12. Use of an Angle-Independent Doppler System for Intraoperative Carotid Endarterectomy Surveillance ..................... 147
Manju Kalra, Todd E. Rasmussen, and Peter Gloviczki

13. Clinical Implications of the Vascular Laboratory in the Diagnosis of Cerebrovascular Insufficiency........................... 155
Ali F. AbuRahma

Index......................................................................................................................................................................................179
v
1
Overview of Cerebrovascular Disease
Ali F.AbuRahma
Stroke is the third leading cause of death in the United Carotid Endarterectomy Trial Collaborators (NASCET)
States,and the second leading cause of death for women study, and the European Carotid Surgery Trialists’ Col-
in the United States.It is the cause of death in approxi- laborative Group (ECST) looked at symptomatic carotid
mately 150,000 to 200,000 Americans annually.The mor- disease.10–12Regardless of which criteria are used to deter-
bidity of those who survive a stroke has a significant mine whether operative intervention is warranted, a
socioeconomic impact on our society. It is estimated surgeon must stay within the accepted perioperative
that strokes account for the disability of two million stroke rate of 3–7% (depending on indication) as recom-
Americans.The cost of medical bills,hospitalization,and mended by the Ad Hoc Committee of the Stroke Council
rehabilitation was estimated to be around $40 billion in of the American Heart Association. What is generally
1996. agreed upon,however,is that early and accurate detection
It has been reported that 75% of patients suffering a of stroke-prone patients remains one of the most impor-
stroke have surgically accessible extracranial vascular tant problems in medicine,since stroke has an immediate
disease.1 Ischemic strokes constitute 80–85% of all mortality of 20–25% within 30 days.Of the survivors of a
strokes, and the remaining 15–20% are caused by cere- first stroke,25–50% will have an additional stroke.
bral hemorrhage.2,3 It has been estimated that ≥50%
carotid stenosis may be responsible for up to 25% of all
Anatomy
ischemic strokes.Large population studies using carotid
ultrasound estimate the prevalence of ≥50% carotid
artery stenosis to be 3–7%.This emphasizes the impor- The aortic arch gives off,from right to left,the innomi-
tance of early detection for stroke prevention. nate (brachiocephalic trunk), the left common carotid,
Significant changes in our thinking and treatment of and the subclavian arteries (Figure 1–1).The innominate
this disease have occurred over the past 50 years,but this artery passes beneath the left innominate vein before it
has been a topic fraught with controversy since the first branches into the right subclavian and the right common
carotid endarterectomy was reported.Eastcott et al.4per- carotid arteries.The vertebral arteries branch off the sub-
formed a carotid resection with reanastomosis of a dis- clavian arteries 2 or 3cm from the arch,but many varia-
eased vessel in a patient who suffered a transient ischemic tions may occur (Figure 1–1).The left common carotid
attack.This was published in 1954,but DeBakey5reported artery may arise from the innominate (bovine arch) in
a successful performance of this procedure earlier. 16% of patients and cross to a relatively normal position
Today, carotid endarterectomy is the most commonly on the left side. The left vertebral artery may arise
performed vascular surgical procedure,however,it is still directly from the aortic arch instead of from the left sub-
controversial. The debate over medical versus surgical clavian arteries (Figure 1–2).The right vertebral artery
treatment for carotid artery disease has been extensively may arise as part of a trifurcation of the brachiocephalic
analyzed in the medical literature over the past 10 years. trunk into subclavian, common carotid, and vertebral
The CASSANOVA,Asymptomatic Carotid Atheroscle- arteries (Figure 1–3).Occasionally,both subclavian arter-
rosis Study (ACAS), Veteran’s Administration (VA) ies originate together as a single trunk off of the arch,or
Cooperative study, and Asymptomatic Carotid Surgery the right subclavian may arise distal to the left subclavian
Trial (ACST) have looked at medical versus surgical artery and cross to the right side.13
therapy in asymptomatic carotid stenosis.6–9 The VA The common carotid arteries on each side travel in
Cooperative study, the North American Symptomatic the carotid sheath up to the neck before branching into
A.F. Aburahma, J.J. Bergan (eds.), Noninvasive Cerebrovascular Diagnosis, DOI 10.1007/978-1-84882-957-2_1, 1
© Springer-Verlag London Limited 2010
2 A.F.AbuRahma
Figure1–1. An illustration showing the aortic arch and its branches:
(1) brachial-cephalic trunk,(2) right subclavian artery,(3) right verte-
13 bral artery,(4) right common carotid artery,(5) right external carotid
artery,(6) right internal carotid artery,(7) aortic arch,(8) left subcla-
vian artery,(9) left vertebral artery,(10) left common carotid artery,
6 12 (11) left external carotid artery,(12) left internal carotid artery,(13)
the basilar artery.
5 11
4 10
3 9
2
1 8
7
Figure1–2. Arch aortogram showing the left vertebral artery orig-
inating from the arch of the aorta with tight stenosis at its origin
(curved arrow) and the right vertebral artery (coming off the right
subclavian artery) with a tight stenosis at its origin (straight arrow).
1. Overview of Cerebrovascular Disease 3
its petrous portion.The cavernous,hypophyseal,semilu-
nar, anterior meningeal, and ophthalmic arteries are
branches of the cavernous portion of the internal carotid
artery.The ophthalmic artery is clinically important since
it communicates with the external carotid system,which
is the basis of the periorbital Doppler study.The remain-
ing branches of the internal carotid artery arise from
the cerebral portion, i.e., the anterior and middle cere-
bral, posterior communicating, and chorioidal branches
(Figure 1–5).
The vertebral artery leaves the subclavian artery and
pushes upward through the foramina of the transverse
processes of the cervical vertebrae into the cranium
through the foramen magnum (Figure 1–6). The neck
spinal branches enter the vertebral canal through the
intervertebral foramen,and muscular branches are given
off to the deep muscles of the neck.These latter branches
anastomose with branches of the external carotid artery.
Intracranially,the vertebral arteries give off the posterior
inferior cerebellar and spinal arteries before they are
united at the pontomedullary junction to form the basilar
artery.The basilar artery terminates as the posterior cere-
bral artery after giving off the anterior inferior,superior
cerebellar,pontine,and internal auditory arteries.
Figure1–3. Abnormal origin of the vertebral artery (H) from
the right common carotid artery (C) in a patient with a retroe-
sophageal right subclavian artery (B). (Courtesy of Springer-
Verlag, Surgery of the Arteries to the Head, 1992, by Ramon
Berguer and Edouard Kieffer,eds.)
internal and external carotid arteries just below the level
of the mandible.The external carotid artery supplies the
face. Important branches of the external carotid artery
include the superior thyroid, which can actually arise
from the common carotid artery,and is important in that
it accompanies the external branch of the superior laryn-
geal nerve,the ascending pharyngeal,and the lingual and
occipital arteries that have a close association with the
hypoglossal nerve (Figure 1–4).No branches of the inter-
nal carotid artery occur in the neck.
The carotid sinus, a baroreceptor, is located in the
crotch of the bifurcation of the internal and external
carotid artery. It is innervated by the nerve of Hering,
which branches from the glossopharyngeal nerve. The
carotid body is a very small structure that also lies in the
crotch of the bifurcation and functions as a chemorecep-
tor, responding to low oxygen or high carbon dioxide
Figure 1–4. Main branches of the external carotid artery:(1)
levels in the blood. It is also innervated by the glos-
superior thyroid, (2) lingual, (3) facial, (4) internal maxillary
sopharyngeal nerve via the nerve of Hering. artery,(5) superficial temporal artery,(6) occipital artery.(Cour-
The corticotympanic artery and the artery to the ptery- tesy of Springer-Verlag, Surgery of the Arteries to the Head,
goid canal are branches of the internal carotid artery in 1992,by Ramon Berguer and Edouard Kieffer,eds.)
4 A.F.AbuRahma
Right Left Left artery (Figure 1–7A).Tortuosity and coiling are thought
nasal nasal frontal to be congenital developmental abnormalities that may
Right artery artery artery
frontal become exaggerated with aging. They usually do not
artery
produce clinical symptoms.
Right Left
supraorbital supraorbital Kinking is a sharp angulation with stenosis of segments
artery artery
of the internal carotid artery,(Figure 1–7B) and appears
to be somewhat different than tortuosity and coiling.
Kinking is less frequently bilateral and usually affects a
Right lacrimal Left lacrimal few centimeters or more above the carotid bifurcation.
artery artery
Poststenotic dilatation may be present. Frequently, an
atherosclerotic plaque on the concave side of the kink
further narrows the lumen.
Right ophthalmic artery Right Left
anterior anterior Left ophthalmic artery
Right middle cerebral cerebral Left posterior
cerebral artery artery artery communicating artery
Left middle
cerebral arter
Right posterior
communicating artery Anterior
communicating
Right posterior artery Left posterior
cerebral artery cerebral artery
Right Left internal
internal carotid artery
carotid Left
artery Right superior
superior cerebellar artery
cerebellar
artery Basilar artery
Right
Left vertebral
vertebral
artery
artery
Anterior
spinal
artery
Figure1–5. Major branches of the internal carotid artery (i.e.,
middle cerebral, anterior cerebral, posterior communicating,
and ophthalmic artery) and vertebrobasilar arteries.
Blood flows through each internal carotid artery at
about 350ml/min,accounting for approximately 85% of
the blood supply to the brain,and the vertebral arteries
account for about 15% of the total blood supply to
the brain.14Therefore,the carotid arteries,both from the
standpoint of accessibility and functioning, become
the system of importance for noninvasive testing.
Figure1–6. Relation of the vertebral artery and cervical spine.
The dotted line indicates the level at which the vertebral artery
Morphologic Variations of the Internal
becomes intradural.As noted, the vertebral artery is divided
Carotid Artery into four portions (V-1,V-2,V-3,and V-4).V-1 is the segment
between its origin and the level where it enters the transverse
Tortuosity of the internal carotid artery (or loop) is gen-
process of the sixth cervical vertebra.V-2 is the segment of the
erally defined as an S- or C-shaped elongation or curving
artery through the foramina of the transverse processes of the
in the course of the artery (Figure 1–7C).Coiling is a term cervical spines until the dotted line.V-3 is the segment between
used to describe an exaggerated, redundant S-shaped C-2 and C-1.V-4 is the segment prior to joining the other ver-
curve,or a complete circle,in the longitudinal axis of the tebral artery to form the basilar artery.