A Spectrum of Doppler Waveforms in the Carotid and Vertebral Arteries
Eric M. Rohren1,
Mark A. Kliewer2,
Barbara A. Carroll3 and
Barbara S. Hertzberg3
1 Mayo Clinic, 200 1st St., SW, Rochester, MN 55905.
2 Department of Radiology, University of Wisconsin, E3/311, 600 Highland Ave.,
Madison, WI 53792-3252.
3 Department of Radiology, Duke University Medical Center, Rm. 2526 Blue Zone,
Box 3808, Durham, NC 27710.
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Fig. 1A. —76-year-old asymptomatic man with normal carotid and
vertebral spectral tracings. Doppler sonogram shows normal internal carotid
artery that supplies low-resistance vascular bed of brain and therefore has
low-resistance waveform. Note sharp rise in flow velocity during systole and
gradual tapering of continuously forward flow throughout diastole. Internal
carotid artery waveform tends to display more blunted systolic peak and
greater diastolic flow than is seen in external carotid artery waveform.
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Fig. 1B. —76-year-old asymptomatic man with normal carotid and
vertebral spectral tracings. Doppler sonogram shows external carotid artery
that supplies high-resistance vascular beds of osseous and muscular structures
of head and neck; thus, waveform is characterized by sharp rise in flow
velocity during systole, rapid decline toward baseline, and diminished
diastolic flow. Transient reversal in early diastole can be seen normally.
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Fig. 1C. —76-year-old asymptomatic man with normal carotid and
vertebral spectral tracings. Doppler sonography waveform of common carotid
artery represents amalgamation of flow profiles of internal carotid artery and
external carotid artery. Normally, common carotid artery waveform assumes
relatively low resistance character because of preponderance of carotid flow
entering internal carotid artery ( 80%). Occasionally, transient flow
reversal may be seen in healthy people. Peak systolic velocities in common
carotid artery can be high in young patients with compliant vessels; such
velocities tend to decrease with age.
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Fig. 1D. —76-year-old asymptomatic man with normal carotid and
vertebral spectral tracings. Doppler sonogram shows normal vertebral artery
waveforms that resemble those of internal carotid artery, because vertebral
artery also supplies low-resistance vascular bed of brain. Typical vertebral
artery waveform is low resistance with continuous forward flow during
diastole.
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Fig. 2. —66-year-old woman with high-grade atherosclerotic stenosis of
proximal right internal carotid artery and parvus–tardus waveforms in
mid internal carotid artery. Spectral Doppler sonography tracings distal to
stenosis show diminished peak systolic amplitude (pulsus parvus) and prolonged
systolic acceleration evident in delayed systolic upstroke and rounded
systolic peak (pulsus tardus). This waveform most often results from
high-grade stenosis, which may occur anywhere from aortic valve to carotid
arteries. If stenosis is central, such as aortic valvular disease,
parvus–tardus waveforms are often identified within both carotid
arteries.
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Fig. 3. —78-year-old woman with severely stenotic aortic valve
complicated by aortic regurgitation. Doppler sonography waveforms from
arteries (right common carotid artery is shown as example) show bisferious
pulse, with prominent mid systolic retraction (arrow) distinct from
dicrotic notch (arrowhead). Dicrotic notch is normal finding and is
because of closure of aortic valve, temporary cessation of forward flow,
followed by resumption of forward flow driven by elastic rebound of aortic
wall. Mechanism of pulsus bisferiens in aortic insufficiency is not well
understood. One view is that first peak represents initial high-volume
ejection of blood, which is followed by abrupt mid systolic flow deceleration
caused by regurgitant valve, and second peak represents tidal wave reflected
from distended aorta as it relaxes or from periphery of body. Others argue
that rapid ejection of large volume of blood (increased preload of left
ventricle) creates transient suction (Venturi) effect in aorta, which in turn
produces mid systolic retraction in carotid artery waveform.
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Fig. 4. —47-year-old man with pulsus alternans caused by idiopathic
dilated cardiomyopathy. Doppler sonogram shows peak systolic velocities in
external carotid artery that oscillate between two levels on sequential beats
(arrows). Note that cardiac rhythm remains regular throughout.
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Fig. 5A. —54-year-old woman with asymptomatic left subclavian stenosis
and presteal waveforms in vertebral artery. Doppler sonogram shows midsystolic
velocity deceleration (arrow) present in left vertebral artery
(VERT). Note echocardiogram tracing indicating beginning of systole at QRS
complex (arrowhead).
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Fig. 5B. —54-year-old woman with asymptomatic left subclavian stenosis
and presteal waveforms in vertebral artery. Drawing shows contour of spectral
tracing in presteal states that has been fancifully compared to rabbit in
profile. Making this imaginative leap facilitates recognition of otherwise
complex waveform pattern.
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Fig. 6A. —83-year-old woman with known atherosclerotic disease of left
subclavian artery. Doppler sonogram shows conversion of presteal waveform to
complete vertebral steal. Spectral tracings from left vertebral artery show
waveform characterized by pronounced mid systolic cleft (arrow) and
transient reversal of flow during systole. This wave pattern indicates
bidirectional flow, represented above and below baseline. This transient
reversal represents progression of mid systolic cleft noted in early presteal
waveform illustrated in Figure
5A,
5B. Note that flow in artery is
antegrade for most of cardiac cycle.
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Fig. 6B. —83-year-old woman with known atherosclerotic disease of left
subclavian artery. Doppler sonogram shows that when blood pressure cuff is
inflated on left arm, then rapidly deflated, there is conversion of waveform
in left vertebral artery from presteal pattern to complete steal pattern, in
which there is total reversal of flow throughout cardiac cycle. Blood pressure
cuff maneuver induces reactive hyperemia in arm and increases blood flow
across subclavian stenosis. Higher velocities within subclavian artery result
in complementary drop in pressure and redirection of blood flow in ipsilateral
vertebral artery toward its now-lower-pressure subclavian origin.
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Fig. 7. —Presteal Doppler sonography waveform appearance in right
external carotid artery of 54-year-old man with atherosclerotic disease of
right brachiocephalic artery. Spectral tracings from right external carotid
artery show waveform similar in appearance to presteal waveforms described in
vertebral arteries (Fig. 5A,
5B). Doppler sonography
tracings from left carotid artery were normal. Stenosis of brachiocephalic
artery is thought to cause jet of flow across origin of right common carotid
artery, leading to transient drop in pressure at peak systole. Mid systolic
retraction is evident in Doppler sonography waveforms.
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Fig. 8. —73-year-old woman with internalization of left external
carotid artery because of complete occlusion of left internal carotid artery.
Doppler sonogram shows that external carotid artery waveform has assumed
contour similar to that of healthy internal carotid artery, with increased
diastolic flow. Most often, collateral blood supply to intracranial arteries
from external carotid system traverses ophthalmic bed.
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Fig. 9A. —78-year-old man with retrograde flow in left external carotid
artery caused by complete occlusion of left common carotid artery. Spectral
Doppler sonography tracing from left external carotid artery shows blood flow
directed toward transducer (note positive velocities on scale). Therefore,
flow in external carotid artery is retrograde toward carotid bulb and then
antegrade in internal carotid artery.
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Fig. 9B. —78-year-old man with retrograde flow in left external carotid
artery caused by complete occlusion of left common carotid artery. Spectral
Doppler sonography tracing from internal carotid artery shows flow away from
transducer (display has been inverted to show waveform above baseline; note
negative velocity measurements on scale). Therefore, flow in internal carotid
artery is antegrade, reconstituted via retrograde flow in external carotid
artery. Note that reconstituted flow in external carotid artery and internal
carotid artery displays low-resistance waveform with diminished systolic
amplitude and delayed systolic upstroke similar to parvus–tardus
waveform. This waveform is seen in 70% of proximal occlusions, presumably
resulting from filtering out of higher frequency velocities by collateral
network supplying external carotid artery, often from contralateral external
carotid artery system.
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Fig. 10. —Water-hammer spectral appearance on sonography of 83-year-old
man with severe aortic regurgitation. Spectral Doppler sonography tracing from
proximal right common carotid artery shows widened pulse pressure signaled by
sharp systolic peak, precipitous deceleration of flow in late systole, and
sustained reversal of flow through diastole. The spectral waveforms mirror
physical examination finding of water-hammer pulses in patients with severe
aortic regurgitation.
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Fig. 11A. —45-year-old man with history of central venous line
inadvertently placed in artery. Color Doppler sonogram shows large
pseudoaneurysm (arrows) with swirling flow in patient's neck. Further
examination revealed neck of pseudoaneurysm arises from mid common carotid
artery (not shown).
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Fig. 11B. —45-year-old man with history of central venous line
inadvertently placed in artery. Proximal to pseudoaneurysm, Doppler sonogram
shows pulse contour in common carotid artery (CCA) is irregular and jagged,
and there is reversal of flow in diastole (arrow), resembling
to-and-fro pattern produced by exchanging currents in pseudoaneurysm neck.
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Fig. 12A. —19-year-old man who sustained gunshot injury to neck. Doppler
sonography waveforms in right vertebral artery show extremely high flow
velocities during both peak systole and diastole, indicating shunt of arterial
flow into low pressure system.
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Fig. 12B. —19-year-old man who sustained gunshot injury to neck. Doppler
sonography waveforms in right internal jugular vein show high volume of
disordered, pulsatile flow.
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Fig. 12C. —19-year-old man who sustained gunshot injury to neck. Color
Doppler sonogram reveals traumatic vertebrojugular arteriovenous fistula
(arrows) that was confirmed on follow-up angiography. JUG V = jugular
vein, VERT = vertebral artery.
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Fig. 13. —Blunt, percussive waveforms in 29-year-old man with complete
occlusion of right common carotid artery because of Takayasu's arteritis.
Spectral Doppler sonography waveforms obtained immediately proximal to
occlusion show only diminutive and dampened percussion and no visible flow
during diastole.
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Fig. 14A. —Bidirectional flow in internal carotid artery of 78-year-old
woman with prior right carotid endarterectomy and recurrent amaurosis fugax.
Spectral Doppler sonography tracings from proximal internal carotid artery
show high-velocity antegrade flow, suggesting high-grade stenosis. Note
presence of intermittent cardiac arrhythmia.
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Fig. 14B. —Bidirectional flow in internal carotid artery of 78-year-old
woman with prior right carotid endarterectomy and recurrent amaurosis fugax.
Spectral Doppler sonography tracings from mid internal carotid artery show
retrograde flow in posterior portion of vessel. This finding suggests second
tandem stenosis distally, producing swirling current of blood in interposed
arterial segment.
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Fig. 14C. —Bidirectional flow in internal carotid artery of 78-year-old
woman with prior right carotid endarterectomy and recurrent amaurosis fugax.
Right carotid arteriogram confirms proximal and distal internal carotid artery
stenosis (arrows).
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Fig. 15A. —Superimposed cyclic flow perturbations in common carotid
artery because of presence of intraaortic balloon pump. Doppler sonogram shows
55-year-old man with ischemic cardiomyopathy. Waveforms in right common
carotid artery show second peak of forward flow (arrow) during
systole corresponding to inflation of intraaortic balloon. At end of diastole,
and immediately preceding next beat, there is transient reversal
(arrowhead) that corresponds to deflation of balloon.
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Fig. 15B. —Superimposed cyclic flow perturbations in common carotid
artery because of presence of intraaortic balloon pump. Doppler sonogram shows
36-year-old man with ischemic cardiomyopathy and intraaortic balloon pump.
Less-organized wave pattern is seen in left common carotid artery of this
patient. Presence of balloon pump complicates analysis of underlying carotid
disease, and measurement of flow velocities may necessitate temporary
deactivation of balloon pump.
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Fig. 16A. —68-year-old asymptomatic woman with percussive waves because
of temporal tap maneuver. Spectral Doppler sonography tracing obtained during
temporal tap (T) shows external carotid artery. Serrate distortion of pulse
contour produced by tapping temporal artery is well defined, with deflection
occurring predominantly toward baseline.
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Fig. 16B. —68-year-old asymptomatic woman with percussive waves because
of temporal tap maneuver. Spectral Doppler sonography tracing obtained during
temporal tap (T) shows internal carotid artery. Changes produced by tapped
percussions are evident in internal carotid artery and external carotid artery
tracings and therefore have been transmitted around carotid bulb. It is
important to examine both carotid vessels under consideration. If these
perturbations are found in only one of two vessels in question, that vessel is
always external carotid artery. When percussive waves are detected in both
vessels, waves are sharper and of higher amplitude in external carotid artery
in 74% of cases.
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Copyright © 2003 by the American Roentgen Ray Society.
