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25 Carotid Dissection in ICU: Usefulness of Bedside Ultrasound Examination…
427
a
d
Fig. 25.3 Ultrasound assessment of ciliospinal reex (CR). (a) Initial probe positing; (b) elicitation of CR; (c) site of stimulation; (d) B-mode visualization of pupil at rest; (e) B-mode visualization of pupil in mydriasis after stimulus; (f) M-mode measurement of pupillary diameter (in blue)
and pupillary dilation time (in yellow)
b
e
c
f
Fig. 25.4 Internal carotid artery dissection: (a) serpiginous stenosis, surrounded by a hypoechogenic thickening of the vessel wall representing the intramural hematoma. (b) Distal tapering
stenosis
25.7 Internal Carotid Artery Dissection (ICAD):
Ultrasound Findings
In patients with ICAD, there are two main types of ultrasound ndings, morphological and hemodynamic; moreover, they can be direct or indirect (Fig.25.4).
428
C. Baracchini and F. Farina
Direct morphological ndings are represented by hypoechogenic thickening of
the vessel wall, lumen narrowing, echolucent intramural hematoma, double lumen,
intimal ap, dissecting membrane, and pseudoaneurysm [31–33]. Notably, pathognomonic signs are found in only one quarter of patients; specically, the detection
rates of an intramural hematoma, a double lumen, and an intimal ap are about
15–25%, ≤2%, and 2%, respectively [19, 23].
Indirect morphological ndings are characterized by a normal carotid bifurcation
or only mild atherosclerotic wall changes [4, 32, 34], distal tapering stenosis,
increase of outer vessel diameter or circumference, and early thrombus detection
[35]. Noteworthy, the most common nding of ICAD, found in 90% of patients, is
a hypoechogenic wall thickening determining a stenosis or occlusion at a site not
typically involved in atherosclerotic disease [31, 36]. Compared to atherosclerotic
luminal narrowing, ICAD stenosis usually begins a few centimeters distal to the
bifurcation and extends over a longer distance [23, 32]. Consequently, beware that
in a patient with a clinical suspicion of ICAD, an examination of the carotid system
must include the distal part of the ICA, especially with a sector probe. In patients
with bromuscular dysplasia, a known risk factor for CAD [37], irregular wall
thickening, multisegmental stenosis, or an aberrant course of the ICA are frequently
found [38, 39]. Morphological criteria alone are diagnostic in only about 50%
(20–63%), mainly due to inadequate direct imaging for retromandibular location.
Regarding direct hemodynamic criteria, these are mainly represented by a signicant increase of blood ow velocities due to a distal stenosis, that is, highcervical, retromastoidal stenosis. Beware when comparing ow velocities with the
contralateral vessel, since up to 25% of patients have dissections affecting multiple
vessels at the same time [6]. The combination of morphological and hemodynamic
criteria is diagnostic in 74–78–95% of ICAD patients and increases with repeated
examinations [19, 32, 33, 40].
Indirect hemodynamic criteria are present in patients with intracranial ICAD and
they are characterized by pre-stenotic high resistance ow proles, post-stenotic
dampened ow proles, and intracranial collateral circulation [19].
Taking into consideration any abnormal nding, sensitivity of combined ultrasound techniques is high ranging from 80% to 96% [4, 19, 32–34, 36, 41–43].
Sensitivity, specicity, and positive and negative predictive values for color-coded
duplex (CCD) sonography diagnosis of patients with ICAD causing carotid territory
ischemia were 96%, 94%, 92%, and 97%, respectively [42]. However, different
ultrasound techniques yield different sensitivities: 82% for CCD, 91% for Power
Doppler (PD), and 98% for B-ow [44]. Intimal aps, ssures of membranes, and
residual ow within the true and false lumen were better detected by B-ow than by
CCD and PD [45]. Compared to CCD and PD, B-ow has a better spatial resolution
and no angle dependency of the probe during the examination; as B-ow is not
based on the Doppler principle, velocity measurements are not possible. Sensitivity
is also different according to symptoms: 96% in patients having suffered ischemic
events and 71% in patients without ischemic events (painful Horner’s syndrome,
cranial nerve palsies: IX–XII or more rarely III, IV, VI) [4, 46]. Accordingly, patients
with ischemic events have more often high-grade stenoses or occlusions (83%) than
those without ischemic symptoms (40%) [4].
25 Carotid Dissection in ICU: Usefulness of Bedside Ultrasound Examination…
Ultrasound has also limitations, as false-negative ndings are reported in
2.8–16% of cases: subadventitial dissections without lumen compromise, low-grade
stenosis with mild mural hematoma, and vessel segment not directly accessible by
ultrasound, [19, 47]. These limitations are more often encountered in patients without cerebral ischemic signs [4]. Since a normal ultrasound exam does not exclude
ICAD, the gold standard for diagnosis is an axial cervical MRI using the T1 fat
suppression technique, as it detects the pathognomonic intramural hematoma in
more than 90% of cases. Yet, MRI and ultrasound are considered complementary
because only ultrasound can show the hemodynamic consequences.
The best method for following patients with CAD is ultrasound as it determines
the time of recanalization and therefore the necessary duration of antithrombotic
treatment. Recanalization, which results from the resorption of the wall hematoma
and from the resolution of the intraluminal thrombus, occurs in about 76% of ICAD;
specically, a complete recanalization has been reported in 55% of patients (58.7%
in case of initial ICA stenosis, 40% in subjects with initial ICA occlusion). Most
lumen changes occur within the rst 6months after dissection and they are only
rarely seen (<1%) after 1 year [27]. High-grade (>80%) stenosis and occlusion
recanalized less frequently [48]. In very selected cases of ICAD associated with
critical hemodynamic insufciency or thromboembolic events that occur despite
medical therapy, the patient undergoes endovascular stent placement; in these
instances, ultrasound is useful in checking treatment efcacy.
Ultrasound monitoring is also valuable for detecting CAD recurrence: two
reports have shown a surprisingly high recurrence rate ranging from 19% to 26% in
the acute phase of the disease [27, 39]. Conversely, late recurrence is an uncommon
event, occurring only in 2.7% of patients [27].
429
25.8 Common Carotid Artery Dissection (CCAD):
Ultrasound Findings
Common carotid artery dissection (CCAD) is a rare disease representing less than
1% of all CADs. This is possibly due to a different ultrastructure of the vessel wall:
the ICA is a muscular artery, whereas the CCA is an elastic artery. The main difference between the two arteries is in the tunica media: in muscular arteries, the tunica
media consists mainly of smooth muscle tissue, whereas in elastic arteries, it consists of mostly elastic bers. Muscular arteries have two elastic layers in the tunica
media (the external elastic lamina and internal elastic lamina), which might make
them more susceptible to dissection [49].
CCAD can be traumatic, iatrogenic, spontaneous, or associated with aortic dissection. Specically, CCAD is the most common mechanism of ischemic stroke of
type A thoracic aortic dissection (AAD), seen in 85% of cases in one series, more
commonly on the right side [50].
The most frequently reported ultrasound ndings (Fig.25.5) include a double
lumen, mural thrombus, intraluminal hyperechoic/isoechoic lesion, and intimal
ap; more rare ndings are carotid occlusion and pseudoaneurysm [3]. When urgent
430
C. Baracchini and F. Farina
a
c
Fig. 25.5 Common carotid artery dissection. (a, c) Longitudinal view showing a double lumen
and a dissecting membrane. (b, d) Axial view showing a dissecting membrane and intramural
hematoma
b
d
ultrasound is performed for suspected CCAD, axial views of the vessel should be
acquired. In cases of CCA occlusion, blood will usually ow from the ECA to the
ICA, even though occasionally ow reversal may be seen with the ICA owing
retrograde and into the ECA.This dynamic information regarding ow within the
ICA and ECA distal to the CCA occlusion provides complementary information for
cerebral angiography and revascularization planning. Given its possible association
with aortic dissection, early recognition of CCAD might affect the decision regarding thrombolysis in acute ischemic stroke patients. Since thrombolysis is potentially
harmful in patients with CCAD secondary to AAD, a chest CT scan is mandatory to
exclude an aortic dissection extending to the cerebroafferent vessels [51].
25.9 Ultrasound ofIntracranial Arterial Dissection
Intracranial ICADs seem to occur most frequently in the supraclinoid segment [52].
Overall they are rare and affect younger patients with a mean age less than 30years.
Clinically, they present with severe headache, ischemic symptoms, or subarachnoid
hemorrhage. An extensive diagnostic workup which includes conventional angiography is usually necessary not to miss a correct diagnosis. The visualization of the
ce
25 Carotid Dissection in ICU: Usefulness of Bedside Ultrasound Examination…
431
mural hematoma in intracranial arteries is very difcult with any non-invasive
method. Ultrasound examination usually shows stenosis or occlusion of the involved
vessel, but there are no data regarding sensitivity or specicity of ultrasound ndings.
25.10 Pupillary Ultrasound: Findings inCarotid Dissection
In patients with CAD, pupillary response to light is comparable on both sides, while
mydriatic dilation after CR elicitation is completely absent ipsilaterally in the acute
phase (Fig.25.6). This nding is especially important when CAD involves the distal
segments and/or is subadventitial, and the pupillary dysfunction is not easily apparent to the clinician’s eye.
25.11 Conclusion
In summary, ultrasound is a fundamental diagnostic tool for patients with a clinical
suspicion of CAD since it is widely available, non-invasive and it has a high sensitivity, especially in patients with signs of cerebral ischemia. Moreover, bedside ultrasound examination of the pupil might reveal a subtle pupillary dysfunction determined
by a hidden distal/subadventitial CAD, especially in the acute phase. This might be
extremely useful when assessing a polytraumatic patient admitted to the ICU.
a
b
Fig. 25.6 Right internal carotid artery dissection. (a, b) Pupillary diameter at rest in both eyes; (c,
d) normal pupillary reex to light in right and left eye; (e) no pupillary reaction to ciliospinal
stimulus (pinching of the trapezius muscle) on the right side; (f) normal mydriatic reaction on the
nonaffected side
d
f
432
C. Baracchini and F. Farina
CAD diagnosis should be conrmed by MRI because of its exquisite sensitivity
in detecting intramural hematoma also in patients with local symptoms only.
Complementarily to MRI, ultrasound discloses hemodynamic consequences in the
intracranial circulation which might indicate the need for an endovascular treatment.
Ultrasound is the method of choice for monitoring recanalization once treatment
is started, detecting CAD recurrence and establishing the duration of antithrombotic
therapy.
Algorithm
Clinical Status of the Patient
ABCD
Level of Consciousness (GCS)
Pupillary Reactivity?
Hemodinamic Stability?
Oxygenation?
DIAGNOSIS
Trauma: PolytraumaticPatient ?
Ischemic Stroke ?
1. Extracranial Color-Coded Sonography (ECCS)
2. Pupillar Ultrasound (PuUS)
3. Transcranial Color-Coded duplex Sonography (TCCS)
ECCS
Pathognomonic
Signs of CAD
NO
Indicative signs
Of CAD
NO
Indirect
Hemodynamic signs
NO Clinical Suspicion and/or
TCCS
Hemodynamic signs
NO
END
YES
YES
YES
YES
PuUS
PuUS
Start Treatment
Indicative Signs of CAD
Indicative Signs of CAD
Dubious Findings
Axial Fat
Suppression MRI
Mural Hematoma
Start Treatment
YES
NO
YES
ABCD Airway-Breathing-Circulation-Disability, GCS Glasgow coma scale, CAD Carotid
Dissection, MRI Magnetic resonance image
25 Carotid Dissection in ICU: Usefulness of Bedside Ultrasound Examination…
433
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435
Chapter 26
Carotid Disease: Usefulness
oftheUltrasound
GyulaPánczél, VendelKemény, LászlóOláh, andLászlóCsiba
Key Points
1. Carotid ultrasound is the rst noninvasive imaging modality for diagnosis and
follow-up of different carotid diseases.
2. Duplex ultrasound (DUS) is the optimal method for investigation.
3. The DUS should assess the degree of stenosis, plaque characteristics, intima-
media- thickness and hemodynamic parameters.
4. Peak systolic velocities of 125–230 cm/s are typical for 50–69% stenosis
(NASCET) and ≥230cm/s for ≥70% internal carotid artery stenosis. But in
some cases, peak systolic velocity ratio, end-diastolic velocity and velocity
ratios may depict better the degree of stenosis.
5. Using spectral Doppler criteria can be also useful for increasing the sensitivity
or specicity.
G. Pánczél
Department of Neurology, Ferenc Flór County Hospital, Kistarcsa, Hungary
e-mail: panczel.gyula@orhosp.hu
V. Kemény
Director of Early Phase Clinical Services at ICON plc, Budapest, Hungary
Szentendre Medical Center, Szentendre, Hungary
L. Oláh
Neurologist, Department of Neurology, Debrecen University, Committee Member - ESNCH,
Debrecen, Hungary
e-mail: olah@med.unideb.hu
L. Csiba (
Neurologist, Department of Neurology, Clinical Center Debrecen University, Debrecen,
Hungary. Advisory Board - ESNCH, Hungarian Neurological Society, Debrecen, Hungary
e-mail: csiba@med.unideb.hu
C. N. Rodríguez et al. (eds.), Neurosonology in Critical Care,
https://doi.org/10.1007/978-3-030-81419-9_26
*)
437© Springer Nature Switzerland AG 2022