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Dear Steve,
I encountered a near occlusion prox ICA where I can only see a tiny trickle flow that stops within 1cm into the ICA lumen. The rest is occluded by a predominantly hypoechoic plaque. The reading shows 16-20cm/s with a ICA appearing waveform from the trickle flow. I tried to pick up color flow distally but I don’t know if the readings are artefactual or real since the velocity is so low and it is not reducible.
In this case, would you try to determine if flow is reconstituted distally? and what does it look like if flow is indeed happening distally?
Best regards,
Linh -
Interesting case Linh,
If the trickle flow was a low resistance waveform it might well be that the ICA is still patent and this is important as a surgical endarterectomy can still be considered.
If the flow is high resistance (the thump before the stump) then it is likely occluded,
Certainly look was distal as you can to try and prove flow,
Use SMI or whatever best low flow technology you have on your machine,
Use a low PRF, its of gain and try a few transducers to prove flow,
If you can not prove flow it is worth doing a CTA study as if there is a trickle it does change management considerably.
Can you upload the pulse Doppler waveform? and other images if you have them.
The CCA waveform is likely externalised as well.
I will have to record my carotid lecture for the website so you can enjoy it.
Steve
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Nice images Linh,
I think there is real flow in this ICA,
The pulse Doppler waveform is low resistance which indicates that there is indeed an outlet for the flow to go to. If there is an occlusion of the ICA I would expect a high resistance waveform in the stump immediately proximal to the occlusion,
The peak systolic velocity is low indicating trickle flow only.
So with good evidence of trickle flow in the ICA it is time to have an assessment with some form of angiography (conventional, CTA or MRA) and a vascular surgical opinion.
Good case Linh.
Let me know what the angiogram shows.
Steve
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Dear Steve,
Thanks for your explanation and the tips of optimising distal flow. Yes, the radiologist did recommend CTA and surgical opinion in his report. I will follow this up and get back to you.
I had to upload this again as the HEIC file from my iphone does not work here. Do you think the waveform is externalised in this distal CCA?
Can’t wait for your next recorded lecture.
Cheers,
Linh -
Yes, I think this wqveform does look externalised,
The way to be sure is to compare with the distal CCA waveform on the other side.
The one on the other side should be a lower resistance waveform.
upload that waveform if you have it handy.
3 lectures are being uploaded now,
One on the foetal heart,
A short one on tennis leg injury assessment,
and a 30 minute lecture called 360 degrees around the elbow
I recorded it for the Korean Pain physicians meeting that was this weekend in Seoul.
I could not attend so recorded the material for them and then did a question and answer session from my home.
The material is similar to the elbow material I have already recorded but there are some new cases and ideas.
Steve.
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Hi Linh,
Yes, it is a bit subtle but there is a difference,
I am looking forward to the angio confirmation.
Also, when you do your Pulse Doppler reduce the PRF (scale) as much as you can so the waveforms fill 90% of the available velocity scale and you will see a nice improvement in the quality of your PW spectrums.
Steve.
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