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69Special Venous Anatomy and Ultrasound Anatomy

Valdueza et al., Neurosonology and Neuroimaging of Stroke: A Comprehensive Reference, Second Edition (ISBN 978-3-13-141872-2), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.

30%

40%

Fig. A2.146 Schematic of the main drainage patterns of the SSS and StS and anatomic variants of the CoS.

SSS

20%

10%

SSS

StSStS

SSSSSS

StSStS

dominance in 25% of cases. Bilaterally symmetric TSs are observed in the remaining 25% of cases.

Position and vessel identiﬁ cation: The TS, CoS, and distal part of the SSS can be visualized through the transtemporal bone window in a modiﬁ ed thalamic, midbrain, or upper pontine axial plane (Fig. A2.142; Video

A2.42). Best results are achieved for the TS if the contralateral side is insonated. At ﬁ rst, the insonation depth has to be increased up to 14 cm to visualize the contralateral skull and the hyperechoic internal occipital protuberance. Then, a small color window with low or maximally reduced PRF is placed above the presumed CoS. Standard TCCS examination of the TS refers to the contralateral side which is identiﬁ ed with a signal away from the probe close to the skull. In general its most proximal part is detected but the TS may be followed over a distance of ~2 cm including the middle and distal segments. The ipsilateral TS with a signal toward the probe is considered to be more diﬃ cult to detect. Extracranial compression of the IJV leads to an immediate reduction or even cessation of ﬂ ow in the ipsilateral TS and an increased ﬂ ow in the contralateral TS if a patent CoS is present (Fig. A2.147; Video

A2.43). Reported detection rates vary between 30% and 60%. To avoid direct insonation of the CoS inﬂ ow region we recommend placing the Doppler sample outside the midline. To identify the SSS, the transducer direction, starting from the CoS or TS, is slightly tilted superior. A signal adjacent to the calvarium, with ﬂ ow direction toward the probe, is considered to be the distal SSS (Fig. A2.148; Video

A2.44). The reported insonation rate is ~50%, but rates of more than 90% have been published considering the detection of the ipsilateral TS with the aid of ultrasound and MR fusion imaging (Zedde et al 2012). A missing TS ﬂ ow signal may be caused by inadequate insonation condition or hypoplasia. The latter can be considered if a prominent ﬂ ow is seen in the contralateral TS, provided that insonation conditions are good. Transient manual occlusion of the dominant IJV may lead to a visible ﬂ ow in the hypoplastic TS, thereby excluding TS occlusion.

Normal values: For ﬂ ow velocities see Table A2.4.

Fig. A2.147 (A) Schematic, axial plane. Note the blue-coded

contralateral and ipsilateral TS as well as the CoS. (B) TCCS, t r a n s t e m p o r a l a p p r o a c h , m i d b r a i n t o u p p e r p o n t i n e a n d m i l d oblique axial plane. Color-mode imaging of the blue-coded contralateral TS over a length of several centimeters (arrows). Note that also the ipsilateral and contralateral M1-MCA, A1-ACA, P1PCA, and P2-PCA as well as the A2-ACA are visible. (C) MR ce T1-weighted image, axial MIP. Note one hypoplastic TS (arrows). (D) Top: Doppler spectrum analysis of contralateral (left) TS at rest (flow velocity 17/12 cm/s) with a flow away from the probe. Bottom left: Increase of flow during right-sided IJV compression. Bottom right: Interruption of flow during left-sided IJV c o m p r e s s i o n .

Sphenoparietal Sinus (SpPS)

Anatomic details: The SpPS can be divided into two parts.

Its ﬁ rst part runs parallel to the MMA along the fronto- temporal surface of the brain. Then the vessel turns and runs without an accompanying artery along the lesser wing of the sphenoid bone toward the anterior segment of the CS. In up to 60% of cases it collects the blood from the sylvian veins, and therefore from a considerable part of the MCA territory.

Position and vessel identiﬁ cation: The SpPS can be in- sonated through the transtemporal bone window using the upper pontine axial insonation plane (Fig. A2.149). We recommend starting to ident ify the hyperechoic lesser wing of the sphenoid bone in the conventional B-mode. Then a small color window with a low PRF setting is placed over this region. The SpPS, or alternatively a strong sylvian vein, can then be identiﬁ ed as a venous signal along the sphenoid bone, aiming toward the carotid siphon (Fig. A2.150; Video directed away from the transducer. Sometimes the distal part of the SpPS is detected in the midbrain plane. It can then be seen anteriorly of the MCA. The SpPS should not be confused with the DMCV: the SpPS runs anteriorly of the MCA while the DMCV has a course dorsal to the MCA (Fig. A2.151). A frequent ﬁ nding is that the ﬂ ow velocity increases the closer the vessel gets to the CS. There venous ﬂ ow velocities may reach up to 80 cm/s, even in completely healthy individuals. The underlying r e a s o n f o r t h i s p h e n o m e n o n m a y b e a p h y s i o l o g i c v e n o u s

A2.45). The ﬂ ow is

70 2 Vascular Anatomy and Structure of Ultrasound Examination

Fig. A2.148 (A) Schematic, sagittal plane. Note the distal part of the SSS (shown in blue). (B) TCCS, transtemporal approach, upper pontine to thalamic axial plane. Color-mode imaging of the distal SSS demonstrated as a red-coded vessel segment. (C) CTA, midsagittal MIP. SSS segments accessible to duplex ultrasound are marked (arrows). (D) Doppler spectrum analysis of the SSS (ﬂ ow velocity 11/ 8 cm/s) with a ﬂ ow toward the probe.

Fig. A2.149 MR T2-weighted image, axial plane (A) and coronal plane (B). MR ce T1-weighted image, sagittal plane (C): Insonation ﬁ eld and transducer position for examination of the SpPS and SPS.

the superior orbital fossa to the top of the petrosal pyramid. It receives blood from the orbit via the superior orbital veins, from the insular and opercular region as well as the temporal lobes via sylvian veins and SpPS. Its main drainage follows the IPS into the superior jugular bulb and via the basal emissaries (foramina lacerum, rotundum, ovale, and spinosum) toward the pterygoid plexus. However, it is also connected with the proximal SiS via the SPS.

Fig. A2.150 (A) Schematic, axial plane. Note the SpPS along the lesser wing of the sphenoid bone toward the CS (shown in blue). (B) TCCS, transtemporal approach, upper pontine axial plane: Color-mode imaging of a blue-coded prominent SpPS. Note the comma-shaped carotid siphon. (C) CTA, axial MIP: Note the close spatial relation of the distal SpPS (arrows) and the carotid siphon (arrow). (D) Doppler spectrum analysis of the SpPS (ﬂ ow velocity 19/16 cm/s) with a ﬂ ow away from the probe.

n a r r o w i n g a t t h e e n t r y i n t o t h e C S ( V a l d u e z a e t a l 1 9 9 8 ) . Detection rates in individuals with a patent transtemporal bone window reach up to 70%.

Normal values: For ﬂ ow velocities see Table A2.4.

Cavernous Sinus (CS)

Anatomic details: The paired CS is a complex venous

structure responsible for collection and distribution of a considerable amount of cerebral blood. It has a length of ~2 cm in the anteroposterior direction, extending from

Position and vessel identiﬁ cation: Due to its com- plex anatomy, the inﬂ ow and outﬂ ow region of the CS is a critical point of analysis. A direct identiﬁ cation of the CS using transcranial ultrasound is currently not possible. Venous signals that are depicted within the region of the CS are most probably feeding or draining vessel segments. Turbulent signals and high ﬂ ow velocities can frequently be seen and should not be confounded with real stenoses or increased ﬂ ow caused by collateral venous function in a presumed veno-occlusive disorder.

Normal values: No normal values have been reported.

Superior Petrosal Sinus (SPS)

Anatomic details: The SPS is in most cases a drainage

pathway for the CS toward the IJV via the SiS, running along the petrous bone in a direction from medial to lateral. However, depending on need, the ﬂ ow direction might also be toward the CS.

Position and vessel identiﬁ cation: The SPS can be visu- alized through the transtemporal bone window between the axial upper and lower pontine planes (Fig. A2.149). If detectable, it is often found as a prominent vessel in the

71Special Venous Anatomy and Ultrasound Anatomy

Fig. A2.151 TCCS , transte mporal approa ch, midbrai n ax ial plane. Color-mode imaging of the SpPS (circled in green) with a ﬂ ow ve- locity of 25/20 cm/s anteriorly of the M1-/M2 MCA junction (A) and of the DMCV with a ﬂ ow velocity of 16/12 cm/s posteriorly of the M1-M2 MCA junction (B).

projection of the C4/C5 segment of the ICA (Fig. A2.152; Video

A2.46). Flow direction can be variable—toward or away from the transducer—but is usually away from the probe. Insonation rates have not been reported.

Normal values: No normal values have been reported.

Inferior Petrosal Sinus (IPS)

Anatomic details: The IPS is an important venous ves-

sel receiving blood from the posterior aspect of the CS. It runs along the petroclival border to the ipsilateral IJV in most cases, or connects to the VVS. Its superior part is cone-shaped with a prominent width of 6–16 mm. Distally, the IPS has a more tubular appearance with a width of 2–7 mm. Right and left asymmetry is frequent, with a right-sided dominance in 75% of cases (Gebarski and Gebarski 1995).

Position and vessel identiﬁ cation: Systematic evaluations have so far only been reported from TCD. Transforaminal insonation yields a venous signal toward the probe at an insonation depth of ~80–90 mm, often simultaneously accompanied by the BA signal. The vessel can also be visualized with TCCS through the upper and lower transforaminal insonation plane using the same identiﬁ cation criteria (Video ed as artiﬁ cial compression of the IJV may lead to under- estimation or overestimation of velocities (Fig. A2.153). Reported TCD detection rates of at least one IPS reach 96% (Doepp et al 1999).

A2.47). Head rotation should be avoid-

Fig. A2.152 (A) Schematic, axial plane. Note the blue SPS along its course at the upper edge of the petrous bone connecting the CS with the SiS. (B) TCCS, transtemporal approach, upper pontine axial plane. Color-mode imaging of a blue-coded SPS indicating ﬂ ow toward the CS (arrows). Note the color signal of the carotid siphon (arrow). (C) CTA, axial MIP. Note the SPS (arrows) being connected with the CS. (D) Doppler spectrum analysis of the SPS: Rare case with prominent ﬂ ow (ﬂ ow velocity 26/12 cm/s) with a ﬂ ow away from the probe.

Extracranial Veins

Internal Jugular Vein

Anatomic details: The IJV receives its blood from

the superior jugular bulb, which collects blood from the SSS and StS via the TS and SiS and also from the CS via the IPS. A right-sided dominance of the IJV diameter and blood ﬂ ow in up to 80% of the population was found in anatomic (Saiki et al 2013), angiographic (Durgun et al 1993), and ultrasound studies (Doepp et al 1998). The side of IJV dominance correlates strongly with a preferred drainage of the SSS into a likewise dominant TS (Saiki et al 2013). Below the superior jugular bulb the IJV runs initially behind and lateral to the ICA but then circumscribes the ICA from lateral to ﬁ nal- ly lie ventrolateral to the CCA in most subjects. However, in a minority of cases, a position ventral, medial, or ventromedial to the CCA may be observed (Troianos et al 2011) (Fig. A2.154). During its course the IJV collects blood from other veins. The main tributaries are the facial vein, the lingual vein, and the retromandibular vein, normally draining together as the thyrolinguofacial trunk into the IJV at the level of the carotid bifurcation (Shima et al 1998). Further caudal tributaries are the superior and medial thyroidal veins, and occasionally the occipital vein (Hacker 1974). Before merging with the subclavian vein to form the brachiocephalic vein it dilates to form the inferior jugular bulb where the commonly paired jugular valves are located. The IJV can be divided into three segments: a proximal (caudal) segment containing the inferior jugular bulb with the bicuspid valves (IJV 1), a middle segment including the thyrolinguofacial trunk additionally collecting blood from extracranial head and neck structures (IJV 2), and a distal (cranial) segment from the skull base to the junction with the thyrolinguofacial trunk collecting mainly intracranial blood (IJV 3) (Fig. A2.131). The IJV

72 2 Vascular Anatomy and Structure of Ultrasound Examination

Fig. A2.153 (A) Schematic adapted to the ultrasound image, axial plane. Note the IPS along its course in the petroclival groove toward the IJV (shown in blue). (B) TCCS, upper transforaminal approach. Color-mode imaging of a prominent long, red-coded IPS segment lateral of the ipsilateral VA and BA. (C) MR ce T1-weighted sequence, coronal plane: Image of both IPS (arrows). Note the wide distance to the BA in this example. However, in case of a tortuous BA both vessels may be insonated simultaneously. (D) Doppler spectrum analysis of the IPS (ﬂ ow velocity 24/19 cm/s) with a ﬂ ow toward the probe.

may, however, also be divided diﬀ erently (Malferrari et al 2014).

Despite of their prominent appearance, the IJVs are not the main drainage pathway of the intracranial blood in all subjects. In the supine body position, the cerebral blood drains mainly via the IJV (deﬁ ned as a drainage of more than two-thirds of the cerebral blood ﬂ ow via the IJV = “jugular drainer”) in ~70% of the general population (Fig. A2.155). The remaining 30% show a nonjugular type or blood draining, predominantly via VVs and deep neck veins (“neck drainer”) or via the intraspinal venous system (“spinal drainer”) (Fig. A2.156) (Doepp et al 2004). Duplex ultrasound also facilitates central cannulation via IJV puncture (see also Chapter 5, “Central Venous Cannulation” under “Ultrasonography of the Internal Jugular Vein in Intensive Care Patients”).

Position and vessel identiﬁ cation: The IJV is insonat- ed like the CCA, ICA, and ECA in cross-sectional and longitudinal insonation planes (Fig. A2.157, top). The Doppler spectrum should be assessed only in the longitudinal plane using angle correction. Velocity variations along the visible vessel course may be caused by variations of the cross-sectional area (CSA). Longitudinal and transversal B-mode insonation of the caudal segment permits the visualization of the inferior jugular bulb and the jugular valves (Lepori et al 1999) (Fig. A2.157, bottom; Video

A2.48). Further cranial, approximately at the level of the carotid bifurcation, the merging thyrolinguofacial trunk can be identiﬁ ed (C.P. Chung et al 2007) (Fig. A2.158; Video

A2.49). In contrast to arterial ultrasound, the patient has to be insonated in a head-straight and strictly supine position

to get reliable and reproducible results. Even a slight turning of the head may lead to one-sided IJV compression with subsequent contralateral IJV or ipsilateral VV ﬂ ow velocity increases. Elevation of the body leads to a redistribution of cerebral venous outﬂ ow toward the VVS (Valdueza et al 2000). Head-down tilting leads to an increased diameter of the IJV (Schreiber et al 2002) which is commonly used to improve catheterization conditions for central intravenous lines. Finally, insonation must be done under normal breathing conditions as huge variations in diameter and ﬂ ow velocity may be induced by forced breathing. However, sometimes changes can even be seen during normal inspiration and expiration. Flow assessment should then be done during a short apnea. Increase in intrathoracic pressure, e.g., by a Valsalva maneuver, leads to a raised IJV diameter and cessation of jugular ﬂ ow, which may also be used in cooperative patients to facilitate placement of a central vein catheter. In up to 30% of the general population a retrograde jugular ﬂ ow is observed during a Valsalva maneuver, which is caused by an IJV valve incompetence (Nedelmann et al 2005b; Doepp et al 2008a) (Fig. A2.159; see also Video

A2.50). There are

diﬀ erent ways to prove IJV valve patency by ultrasound (Nedelmann et al 2007). We recommend insonating the IJV in its middle segment (IJV 2) for assessment of jugular valve competence and in its cranial segment (IJV 3) for the assessment of the drainage of intracranial blood. Compression of a nonhypoplastic IJV with normal ﬂ ow will usually lead to a contralateral IJV increase, provided that both TSs are patent and they are connected via the CoS. In the normal population this occurs in up to 63% during right IJV compression and in up to 48% during left IJV compression (Doepp et al 1998). The achievable increase of ﬂ ow velocity is between 15% and 80%.

Assessment of venous blood volume ﬂ ow (BVF) (for further reading, see also Chapter 3, “Cerebral Blood Flow Volume” under “Parameters of Cerebral Hemodynamics”) should also be performed in a strictly supine position, preferably in the cranial segment to measure almost exclusively intracranial BVF. First, the CSA of the IJV is manually encircled in the horizontal plane using B-mode imaging, avoiding any compression of the vessel by the probe. Second, the time averaged and angle-corrected blood ﬂ ow velocities over at least 5 seconds are assessed in the corresponding longitudinal plane. For correct measurements the sample volume should enclose the whole vessel diameter. In cases of marked respiratory variations of the CSA or ﬂ ow velocities the measurements can be performed during brief apnea after normal exhalation. For BVF calculation the measured CSA and ﬂ ow velocities are automatically multiplied by the duplex machine.

Normal values: Waveforms can vary considerably. Also, absent ﬂ ow may be observed even in a wide-open IJV (Doepp et al 2004, Valdueza et al 2000). Biphasic proﬁ les are more frequent (57%) than monophasic ﬂ ow patterns (Pucheu et al 1994). Prominent ﬂ ow modulations by normal inspiration and expiration can be observed especially in elderly people. For ﬂ ow velocities see Table A2.4.

73Special Venous Anatomy and Ultrasound Anatomy

Medial L a t e r a l

IJV

CCA

CCA CC A CCA

IJV

1% 4.5% 22.5% 49.8% 22.2%

Fig. A2.155 Example of a “jugular drainer” at rest in the supine body position. (A) Ce 3D MRA, axial source image. Note the dominant IJV on both sides (arrows). (B,D) Extracranial duplex, B-mode image: Corresponding prominent IJV in the axial (B) and longitudinal (D) insonation plane. (C) Doppler spectrum analysis demonstrating a prominent monophasic ﬂ ow. (Reproduced from Doepp et al. How does the blood leave the brain? A systematic ultrasound analysis of cerebral venous drainage patterns. Neuroradiology 2004;46:565–570, with permission of Springer.)

Fig. A2.156 Example of a “nonjugular drainer” at rest in the supine body position. (A) Ce 3D MRA, axial source image. Note a weak signal in the left IJV (arrow) and absent right IJV; conversely, strong VVs (arrowheads) and deep neck veins (arrows) with a right-sided dominance can be seen. (B,D) Extracranial duplex, B-mode image, axial and longitudinal plane. An open right IJV is seen. (C) Doppler spectrum analysis reveals however an absent ﬂ ow despite an open IJV lumen. (Reproduced from Doepp et al. How does the blood leave the brain? A systematic ultrasound analysis of cerebral venous drainage patterns. Neuroradiology 2004;46:565–570, with permission of Springer.)

Fig. A2.154 Schematic of the CCA-IJV variants on the right side (adapted from Troianos et al 2011). Note the most common position of the right IJV is ventrolateral of the CCA. In

22.5% the IJV position is anterior of the CCA

CCA

IJV

which might complicate IJV puncture and increase the risk of CCA injury.

IJV 3

CBA

Fig. A2.157 Top: Extracranial duplex, longitudinal plane: Doppler spectrum analysis and color-mode image of the IJV (coded blue). Note the adjacent red-coded CCA. Bottom: Serial B-mode ima ge of a jugular valve. (A) Open valve. (B,C) Valve closing.

Fig. A2.158 Color-coded duplex sonography of the three internal jugular vein (IJV) segments in cross-sectional insonation plane: Top: The smaller cranial (IJV 3) segment, lateral of the ICA. Middle: The

IJV 2

IJV 1

middle (IJV 2) segment ventral of the CCA including the thyrolinguofacial trunk inﬂ ow. Bottom: The large caudal (IJV 1) segment of the jugular bulb at the level of the venous valve.

74 2 Vascular Anatomy and Structure of Ultrasound Examination

Fig. A2.159 Top: Extracranial duplex, cross-sectional B-mode image of the IJV at rest (left) and under Valsalva maneuver (right). Note the distinct enlargement of IJV lumen during Valsalva. Bottom: Doppler spectrum with normal jugular ﬂ ow (left). Flow reversal during Valsalva maneuver (start indicated by the arrow) instead of ﬂ ow interruption in a patient with jugular valve incom- petence (right).

Vertebral Vein

Anatomic details: The VVs are one of four longitudi-

nal channel systems of the VVS draining the cerebral blood. Corresponding to the VA the VV can be divided into three segments: VV 1 (caudal), VV 2 (transforaminal), and VV 3 (suboccipital) (Fig. A2.131). Similar to the IJV anatomy, bicuspid valves are present in the caudal VV (Chou et al 2002). In contrast to the IJVs, the VVs do not collapse when body position changes from supine to upright, because of their intraforaminal course. Instead, the vessel diameter slightly increases while ﬂ ow increases markedly. In parallel, there is a profound ﬂ ow reduction in the IJVs (Fig. A2.160 and Fig. A2.161), but the VVs compensate for only ~25% of the reduction in jugular drainage (Valdueza et al 2000). Alternate pathways like the intraspinal compartment of the VVS are therefore assumed to be activated.

Position and vessel identiﬁ cation: For VV insonation we recommend ﬁ rst visualizing the V2 segment of the VA. Care must be taken to adjust the ultrasound system for low ﬂ ow velocities (low PRF). Also, concomitant IJV c o m p r e s s i o n , w h i c h u s u a l l y l e a d s t o a p r o m p t i n c r e a s e o f ﬂ ow velocity, has to be avoided (see also Video If the artery is identiﬁ ed, the VV 2 is usually seen in the midcervical region generally as a singular vessel accompanying the VA ventrally or as two vessels which run parallel to the VA on either side. The ﬂ ow direction is inverse to the VA toward the heart.

Proximal to its intraforaminal course (caudal of the C6 segment) the VV can be followed further into the VV 1 segment within the VA vicinity where it becomes larger. According to our experience, the blood ﬂ ow ve- locity in this region is often signiﬁ cantly higher than in the cranial segments, probably due to the inﬂ ow

A2.51).

Fig. A2.160 Schematic illustrating the postural dependency of

the cerebral venous drainage. To p: Venous vessel CSA and appearance during variations of volume and transmural pressure. Left: In the supine position, the IJV is wide and—depending on the volume state and the central venous pressure—its shape is oval or round. The blue marked VV is open but usually shows a low ﬂ ow. Note the small diameter. Right: In the upright position, the IJVs collapse and the ﬂ ow may show complete cessation while the VV simultaneously shows slight compensatory dilation but also increased ﬂ ow.

Fig. A2.161 Ultrasound imaging to document the postural dependency of the cerebral venous drainage. Left: Extracranial duplex, B-mode, transversal planes showing a stepwise collapse of the IJV (yellow circle) from the lying position (0°) to the upright position (90°). Right: In the same subjec t there is a compensatory marked increase of ﬂ ow velocity and volume ﬂ ow in the VV in the standing position.

of intersegmental radicular veins of the intraspinal VVS. The VV normally drains into the brachiocephalic vein but may also merge into the IJV (Fig. A2.162, Fig. A2.163, Fig. A2.164). Reference data for VV ﬂ ow is available from one publication only (Hoﬀ mann et al

1999). VV 2 detection rates in the supine body position of a normal population are bilaterally 62% and unilaterally 17%. Only 21% of cases do not show any VV signal. Detection rates decrease with increasing age and signiﬁ cantly increase in an upright body position (Doepp et al 2010, Valdueza et al 2000). Bilateral compression of the IJV leads in many cases to a VV ﬂ ow increase of

75Special Venous Anatomy and Ultrasound Anatomy

Fig. A2.162 Extracranial duplex. Top l eft : Lo ngi tud inal B-mo de VV and VA image. VA diameter 3.8 mm, VV diameter 1.3 mm. Bottom left: Corresponding color-mode image. Note the intersegmental radicular veins connecting the VV with the anterior intraspinal segment (arrowhead) and a second VV medially of the VA (arrow). Top r igh t: VA Doppler spectrum (ﬂ ow velocity 63/25 cm/s). Middle right: VV Doppler spectrum (ﬂ ow velocity 24/21 cm/s). Bottom right: VV ﬂ ow velocity increase during ipsilateral IJV c o m p r e s s i o n .

more than 100%, which underlines its importance as collateral pathway in IJV obstruction (Schreiber et al 2003d).

BVF can be best assessed between intertransversal segments C4/C5 or C5/C6, i.e., within the VV 2 segment (Doepp et al 2004). The CSA can only be estimated from a diameter measurement in the longitudinal plane, assuming a cylindrical vessel shape (Fig. A2.161, right). BVF calculation from Doppler spectra and CSA is then performed in the same manner as described for the IJV.

Normal values: For ﬂ ow velocities see Table A2.4.

Fig. A2.163 Left: Schematic of the radicular veins (1) and the ver-

tebral vein (2). Right: Extracranial duplex, longitudinal B-mode, color-mode, and Doppler spectra images. To p: Prominent intersegmental radicular vein signal with ﬂ ow direction from in- traspinal toward the VV (ﬂ ow velocity 25/16 cm/s). Middle: The radicular vein is crossing the VA with subsequent simultaneous arterial and venous Doppler spectrum delineation. Bottom: VV signal with ﬂ ow direction toward the heart (ﬂ ow velocity 60/8 cm/s).

Fig. A2.164 Extracranial duplex, color-mode, longitudinal plane. Left: B-mode image demonstrating a large VV (arrows) merging into the IJV (arrow). Right: Corresponding color-mode images.

76 2 Vascular Anatomy and Structure of Ultrasound Examination

Table A2.2 Reference values of extracranial arterial blood ﬂ ow velocities assessed by duplex sonography

Vess el Systolic ﬂ ow v

elocity (cm/s) Diastolic ﬂ ow velocity (cm/s) Reference

CCA* 96 ± 25 26 ± 6 Schöning et al 1994

ICA* 66 ± 16 26 ± 6 Schöning e

ECA main stem* 83 ± 17 17 ± 5 Schöning et al1994

STeA 57 ± 2 Lauwerys et al1997

OccA 54 ± 21 6 ± 5 Tee et al 2013

MMA 26 ± 8 5 ± 3 Alijagic-Schultze et al 2009

V0-VA R* 66 ± 18 16 ± 5 Kuhl et al 2000

V0-VA L* 61 ± 17 16 ± 5

V1-VA R* 60 ± 14 16 ± 5 Kuhl et al 2000

V1-VA L* 58 ± 10 17 ± 5

V2-VA R* 49 ± 11 16 ± 5 Kuhl et al 2000

V2-VA L* 51 ± 10 16 ± 4

SA No systematic data available

BrA* 81 ± 3 5 ± 1 Özcan et al 2006

†

AxA

77 (64–94) Not reported Stapleton et al 2008

Note: values are given as mean ± SD (range). * Angle-corrected.

†

45° arm abduction.

t al1994

Table A2.3 Reference values of intracranial arterial blood ﬂ ow velocities assessed by TCCS

Vess el Systolic ﬂ ow velocity (cm/s) Diastolic ﬂ ow velocity (cm/s) Reference

C6-ICA 53 ± 14

(27–106)

C6-ICA* 66 ± 15

(34–113)

25 ± 7 (13–48)

31 ± 8 (17–52)

Egger

s et al 2009

Eggers et al 2009

C5-ICA 49 ± 16 19 ± 7 Jurgita et al 2002 C3/C4-ICA 57 ± 17

(31–105)

C1/C2-ICA 77 ± 21

(33–140)

C1/C2-ICA* 93 ± 18

(64–118)

OA (transorbital) 35 ± 10

(15–67)

25 ± 8 (12–53)

34 ± 10 (12–65)

43 ± 6 (34–49)

14 ± 5 (4–36)

Eggers et al 2009

Schreiber et al 2006

OA (transtemporal) 33 ± 9 11 ± 4 Schreiber et al 2006 CRA (transorbital) 17 ± 3

(15–58)

M1-MCA* 108 ± 18

(63–152)

6 ± 3 (4–25)

48 ± 8 (23.73)

Tranquart et al 2003

Schöning et al 1993

Early temp. M1 branch 44 ± 20 20 ± 7 Rogge et al 2015 M2-MCA 60 ± 20 20 ± 10 Rogge et al 2015 M3-MCA

(inﬂ ow angular artery) A1-ACA* 91 ± 17

53 ± 15 (30–82)

(53–137)

25 ± 7 (13–40)

40 ± 8 (18–58)

Rogge et al 2008b

Schöning et al 1993

A1-ACA 82 ± 17 39 ± 7 Rogge 2008a A2-ACA 51 ± 12 24 ± 6 Rogge 2008a A4-ACA (pericallosal artery) 31 ± 10 14 ± 4 Rogge 2008a V4-VA* 60 ± 16

(29–95)

27 ± 9 (9–50)

Schöning et al 1992

PICA 48 ± 5 26 ± 4 Kaps et al 1992a BA transforaminal* 67 ± 16

(35–114)

BA transforaminal 68 ± 13

(41–104)

BA transtemporal 39 ± 13

(18–77)

33 ± 8 (18–48)

33 ± 8 (20–56)

19 ± 6 (9–38)

Schöning et al 1992

Own data

AICA No systematic data available SCA 51 ± 13

(29–86)

P1-PCA 60 ± 14

(27–103)

P2-PCA 63 ± 14

(37–123)

P3-PCA 63 ± 12

(30–94)

ATA-PCA 25 ± 9

(12–60)

OTA-PCA 36 ± 9

(15–109)

POA-PCA 44 ± 16

(20–100)

CA-PCA 36 ± 12

(14–73)

24 ± 7 (13–43)

28 ± 9 (11–52)

30 ± 10 (17–72)

30 ± 8 (18–58)

13 ± 4 (5–29)

18 ± 7 (8–60)

23 ± 9 (10–62)

18 ± 7 (7–41)

Pade et al 2010

Frid et al 2015

rid e

t al 2015

Frid et al 2015

PCoA 36 ± 15 Not reported Klötzsch et al 1996b

77Special Venous Anatomy and Ultrasound Anatomy

Note: values are given as mean ± SD (range). * Angle-corrected.

78 2 Vascular Anatomy and Structure of Ultrasound Examination

Table A2.4 Reference values of extracranial and intracranial venous blood ﬂ ow velocities assessed by duplex sonography, TCCS, or TCD

Vess el Systolic ﬂ ow v

elocity (cm/s) Diastolic ﬂ ow velocity (cm/s) Reference

DMCV 9 ± 3 6 ± 2 Stolz et al 1999c

BVR 12 ± 4 9 ± 3 S

tolz et al 1999c

ICV 7 ± 2 5 ± 1 Stolz et al 1999c

VG 12 ± 4 8 ± 3 Stolz et al 1999c

StS 12 ± 5 9 ± 4 Stolz et al 1999c

StS * 26 (12–39) 17 (7–27) Baumgartner et al 1997b

TS 14 ± 6 10 ± 5 Stolz et al 1999c

TS* 32 (9–56) 21 (5–38) Baumgartner et al 1997b

SSS 10 ± 4 6 ± 3 Stolz 1999c

†‡

SpPS

18 ± 6

Valdueza et al 1999a

(11–29)

SPS No systematic data available

IPS

†

20 ± 9

Doepp et al 1999

(8–53)

IJV-R 28 ± 15

(5–77)

IJV-L 22 ± 16

(0–67)

VV-R 24 ± 12

(8–66)

VV-L 24 ± 13

(5–81)

21 ± 14 (0–70)

18 ± 14 (0–59)

8 ± 8 (0–30)

Pucheu et al 1994

Hoﬀ mann et al 1999

Note: values are given as mean ± SD (range). * Angle-corrected.

†

Mean blood ﬂ ow velocity.

‡

Data not representative.

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