CH 22 & 23: atypical vascular disorders & alternative tests and therapeutic interventions

The majority of blood flow reducing lesions are related to ____________ changes.

Atherosclerotic

Although a majority of blood flow reducing lesions are related to atherosclerotic changes, there are still some nonatherosclerotic related pathologies.

List 3 nonatherosclerotic changes.

• Subclavian steal

• Takayasu’s Arteritis

• Temporal arteritis

Name the pathology:

“A condition in which blood going to the brain is shunted away from the cerebral circulation because the subclavian or innominate artery has a high-grade stenosis or occlusion proximal to the takeoff of the vertebral artery.”

Subclavian steal

Subclavian steal syndrome is when…

1. The blood going to the brain is shunted away from the cerebral circulation because the _________ or ________ artery…

2. Has a high-grade _________ or _________ proximal to the takeoff of the…

3. ________ artery

1. Subclavian or Innominate

2. Stenosis or occlusion

3. Vertebral

Subclavian steal syndrome can result in (1)_________ flow in the ipsilateral (2)________ artery to provide blood flow to the arm.

1. Retrograde

2. Vertebral

List the crossed-out parts on this structure.

1. Aortic Arch

2. Innominate

3. Right Subclavian

4. Vertebral

5. Right CCA

6. Right ICA

7. Right ECA

8. Basilar

9. Left ECA

10. Left ICA

11. Left CCA

12. Vertebral

13. Left Subclavian

Where will a stenosis or occlusion be found with subclavian steal syndrome? (2)

• Subclavian artery

• Innominate artery

Where will retrograde flow be seen with subclavian steal syndrome?

Vertebral artery

Label the crossed-out structures on this image.

1. Vertebral artery

2. Basilar artery

3. Blocked subclavian artery

The vertebral artery normally takes blood __________ brain.

To the

The abnormal vertebral artery will take blood __________ brain.

Away from

1. What pathology is occurring here? 

2. Explain why you think that. 

1. Subclavian Steal

2. The blockage in the subclavian steal syndrome has caused retrograde flow in the ipsilateral vertebral artery. 

Patients with subclavian steal syndrome typically present with what symptoms?

Asymptomatic

Subclavian steal syndrome is more common on which side of the neck?

Left

Which side of the neck will present with a lower brachial blood pressure if a patient is suffering from subclavian steal syndrome on the right?

Right

Which side of the neck will present with a lower brachial blood pressure if a patient is suffering from subclavian steal syndrome on the left?

Left

Which side of the arm will present with a decrease in pulses if a patient is suffering from subclavian steal syndrome on the right?

Right

Which side of the arm will present with a decrease in pulses if a patient is suffering from subclavian steal syndrome on the left?

Left

Pulses in the affected arm of subclavian steal syndrome are…

Decreased

1. How does flow resistance appear in the vertebral artery with subclavian steal syndrome?

2. Explain why.

1. Increased

2. Due to feeding a higher resistance bed of the upper extremity

Why would flow resistance increase in the vertebral artery with subclavian steal syndrome?

Because it is feeding a higher resistance bed of the upper extremity

List the 4 treatment options available for subclavian steal syndrome.

• Bypass graft

• Endarterectomy

• Balloon angioplasty

• Stenting

Flow resistance in subclavian steal syndrome goes from (1)____ to (2)____ when it is feeding a higher resistance bed of the upper extremity.

1. Low

2. High

This waveform was dopplered at the vertebral artery. 

1. Does this waveform appear normal or abnormal?

2. If abnormal, explain why.

1. Normal

This waveform was dopplered at the vertebral artery. 

1. Does this waveform appear normal or abnormal?

2. If abnormal, explain why.

1. Abnormal

2. • Retrograde

   • High resistive

Pick the best option: Blood flow in the ipsilateral vertebral artery may have an early systolic deceleration 

• Subclavian stenosis 

• Complete occlusion

Subclavian stenosis

Describe the ‘bunny in profile.’

When a waveform has an early systolic deceleration

What is the name of the waveform finding when there is an early systolic deceleration?

Bunny in profile

A progression of subclavian steal syndrome will show flow in the ipsilateral vertebral artery as…

Bidirectional 

What is another term for ‘bidirectional flow’?

To-Fro

List the 2 ways the waveform can change with progressive subclavian steal syndrome.

• Bidirectional (To-Fro)

• Complete flow reversal

Subclavian Steal Syndrome that has progressed pass the bidirectional flow stage can then show what? 

Complete flow reversal

1. What is seen here?

2. What pathology can be associated with this finding?

1. Early systolic deceleration (bunny in profile)

2. Subclavian steal syndrome

1. What is seen here?

2. What pathology can be associated with this finding?

1. Bidirectional flow (To-Fro)

2. Incomplete steal (Subclavian steal syndrome)

1. What is seen here?

2. What pathology can be associated with this finding?

1. Complete flow reversal

2. Complete steal (Subclavian steal syndrome)

List the sonographic characteristic of an incomplete steal?

Bidirectional flow (To-Fro)

List the sonographic characteristic of a complete steal?

Complete flow reversal

Takayasu’s Arteritis is thought to be an ____________ disorder.

Autoimmune

Name the pathology:

“A fairly rare disease involving inflammation in the walls of the largest arteries (aorta and its main branches)”

Takayasu’s Arteritis

Describe what ‘Takayasu’s Arteritis’ is.

Inflammation in the walls of the largest arteries in the body

Takayasu’s Arteritis involves what structures? (2)

• Aorta

• Aortic branches

Inflammation of the arterial walls will cause it to do what? (2)

• Thicken

• Narrow 

The ‘Pulseless Disease’ is another name for which pathology?

Takayasu’s Arteritis

How will the resulting arterial stenosis or occlusion from Takayasu’s Arteritis affect the rest of the body?

Causes a weak pulse or loss of pulse in the arms or legs

Which pathology in this lecture can lead to a weak pulse or loss of pulses in the arms or legs?

Takayasu’s Arteritis

Takayasu’s Arteritis can also be referred to as the ____________ disease.

Pulseless

Why is Takayasu’s Arteritis referred to as the ‘Pulseless Disease’?

Due to the stenosis or occlusion causing a weak pulse or loss of pulse in the arms or legs

This was seen at the patient’s aorta. 

1. How does it appear sonographically?

2. What pathology can be assumed here?

1. Inflamed arterial walls (thickened and narrow)

2. Takayasu’s Arteritis

This was seen at the patient’s aorta. 

1. How does it appear sonographically?

2. What pathology can be assumed here?

1. Inflamed arterial walls (thickened and narrow)

2. Takayasu’s Arteritis

This was seen at the patient’s aorta. 

1. How does it appear sonographically?

2. What pathology can be assumed here?

1. Inflamed arterial walls (thickened and narrow)

2. Takayasu’s Arteritis

This was seen at the patient’s aorta. 

1. How does it appear sonographically?

2. What pathology can be assumed here?

1. Inflamed arterial walls (thickened and narrow)

2. Takayasu’s Arteritis

List the 9 possible symptoms a patient with Takayasu’s Arteritis can have.

• Dizziness

• Headaches

• Fainting

• Weakness

• Fatigue

• Chest pain

• Hypertension

• Heart attack

• Stroke

Takayasu’s Arteritis is more common in which gender?

Females

Takayasu’s Arteritis is more common in women. 

Which specific demographic women in more prone? (2)

• Young women

• Teenage girls

What is the best imaging modality to use for Takayasu’s Arteritis?

Angiography

On an angiogram, how will Takayasu’s Arteritis appear?

Tubular narrowing of the large arteries

What is the main treatment option for Takayasu’s Arteritis?

Steroid administration (Prednisone) 

Prednisone is used to treat what pathology?

Takayasu’s Arteritis

Prednisone is used to treat Takayasu’s Arteritis.

What does it help with?

Reducing inflammation

A 33-year-old women comes in complaining of worsening headaches that can even lead to fainting episodes. She has a history of high blood pressure. 

1. What can be seen sonographically?

2. What pathology can be assumed here?

1. Inflamed arterial walls (Thickened and narrow)

2. Takayasu’s Arteritis

Name the pathology:

“The inflammation of the superficial temporal artery and/or its branches.”

Temporal arteritis

What is Temporal Arteritis?

Inflammation of the superficial temporal artery and/or its branches

List the 5 symptoms associated with Temporal Arteritis.

• Headaches

• Tenderness on palpation of the distal superficial temporal artery

• Ipsilateral visual changes

  • Blindness

  • Double vision

What is the key sonographic feature of Temporal Arteritis?

Anechoic halo around the vessel lumen

List the 2 sonographic findings of Temporal Arteritis.

• Narrowed segment of the vessel

• Anechoic halo around the vessel lumen secondary to edema

The anechoic halo seen on Temporal Arteritis is secondary to what other pathology?

Edema

What treatment option is available for Temporal Arteritis? 

Steroid therapy

What is needed for a definitive diagnosis of Temporal Arteritis? 

Biopsy

What pathology is seen here?

Temporal Arteritis

How should normal anatomy appear on the films of an arteriogram?

Contrast completely filling the vessel

If a filling defect was seen on an arteriogram, is that normal or abnormal?

Abnormal

If a filling defect was seen on an arteriogram, what can that be an indication of?

Arterial abnormality

What can be used to calculate the percentage of stenosis on the basis of vessel diameter? (2)

• Percentage stenosis calculation

• Diameter reduction

The percentage stenosis calculation or diameter reduction can be used to calculate the percentage of (1)________ on the basis of vessel (2)___________.

1. Stenosis

2. Diameter

What is the formula for diameter reduction?

1 - (d/D) x 100

1. What exam is seen here?

2. If this was imaged at the neck, what vessel is the white arrow?

3. Red arrow?

4. Blue arrow?

1. Arteriogram

2. ICA

3. ECA

4. CCA

Which imaging modality is very sensitive to the presence of stenosis, leading to an overestimation of the severity of disease process?

MRI

How does an MRI affect the imaging of a stenosis?

Sensitive to stenosis, therefore can overestimate the severity of the disease process

Why would an MRI be done instead, if a carotid ultrasound couldn’t be done? (2)

• Limited

• Equivocal

What imaging is seen here of the cranial vessels?

MRI

CT can be done to evaluate for cerebrovascular disease, specifically, to evaluate for the presence or absence of what 5 pathologies?

• Cerebral infarctions

• Hemorrhage

• Tumors

• Masses

• Anatomic variations

Which imaging modality is used with cerebrovascular disease and to evaluate the status of the extracranial and intracranial vessels?

CT/CTA

What can CTA be used for if not to look for a certain pathology? 

Evaluate the status of the extracranial and intracranial vessels

What can CTA be used to look for? (6)

• Patency

• Stenosis

• Occlusion

• Hemorrhage

• AV malformations

• Intracranial aneurysms

What imaging modality is seen here?

CT/CTA

List the 4 risk factors to control for arterial disease. 

• Blood pressure medication

• Weight control

• Stop smoking

• Management of diabetes

List the 3 pharmacological therapies done to treat arterial disease. 

• Aspirin

• Antiplatelet/Antithrombotic medication

• Statin therapy (Lower cholesterol) 

Why is statin therapy used for patients managing arterial disease?

Lowers cholesterol

Name the procedure:

“Surgical removal of intraluminal atherosclerotic material”

Endarterectomy

An Endarterectomy is the surgical removal of what kind of material? 

Intraluminal atherosclerotic

What can change about the vessel after a carotid endarterectomy?

Geometry of the vessel

What is used after a carotid endarterectomy has been performed?

Patch closure

How will a patch closure affect the geometry of the vessel after a carotid endarterectomy has been done? (2)

• Diameter decreases

• Increased velocities

The atherosclerotic process following an endarterectomy can result in what?

Restenosis

The narrowing of the vessel wall within 6 months to 2 years following an endarterectomy is usually attributable to what pathology?

Neointimal hyperplasia

The narrowing of the vessel wall within what time span following an endarterectomy is usually attributable to neointimal hyperplasia?

6 months to 2 years

A stent acts as a…

Scaffold

A stent is designed to do what? (2)

• Maintain intraluminal structure

• Patency of an artery

Why does post operative surveillance of stented arteries with carotid duplex not rely on the same interpretive guidelines used for diagnosis of a stenosis? 

Because some flow acceleration is a normal finding in a stented vessel

Is it normal to see flow acceleration when dopplering inside a stented artery?

Yes