Severe extracranial carotid artery disease

Case contributed by Brendan Cullinane

Presentation

Referred for a carotid ultrasound to investigate dizziness. He was an ex-long-term-smoker. He appeared vague and with slow comprehension.

Patient Data

Age: 80s
Gender: Male
Ultrasound
  • A heavy plaque load was seen at both carotid bifurcations on B-mode ultrasound.
  • On the right, the plaque appeared to be calcified and causing significant stenosis within the internal carotid artery (ICA).
  • Right common carotid artery peak systolic veocity (PSV) was 87 cm/s. Parameters for grading the ICA stenosis were PSV = 367 cm/s, EDV = 140 cm/s, PSV ratio = 4.2. The overall impression was of a low-grade 80-99% stenosis within the right ICA.
  • In view of the normal PSV seen within the right CCA and the plaque loading at the bifurcation, peak systolic velocity within the right external carotid artery (ECA) suggested a low-grade >50% stenosis rather than collateralisation.
  • Blood flow within the right vertebral artery was antegrade but low-velocity. Its origin at the right subclavian artery could not be located. Increased velocities would be expected with collateralisation. There may be tapering distally or further disease outside the limits of the exam.
  • There was mixed plaque within the left ICA. A maximum PSV of 462 cm/s in the left ICA.
  • A maximum end-diastolic velocity (EDV) of 128 cm/s was seen in the left ICA. 
  • The PSV in the left common carotid artery (CCA) was 86cm/s. Parameters for grading the left ICA stenosis were: PSV = 462cm/s, EDV = 128 cm/s, PSV ratio = 5.4. The overall impression was of a high-grade 70-79% to low-grade 80-99% stenosis.
  • In view of the normal PSV seen within the left CCA and the plaque loading at the bifurcation, peak systolic velocity within the left ECA suggested a low-grade >50% stenosis rather than collateralisation.
  • Blood flow within the left vertebral artery was antegrade and of normal velocity. Its origin at the left subclavian artery could not be located. Increased velocities would be expected with collateralisation. There may be tapering distally or further disease outside the limits of the exam.

To sum up:
Bilateral high-grade, haemodynamically significant internal carotid artery disease. Bilateral low-grade, haemodynamically sigificant external carotid artery disease. Lack of collateralisation of both vertebral arteries.

Findings suggest decreased perfusion of the brain.

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Case information

rID: 21860
Published: 23rd Feb 2013
Last edited: 14th Aug 2019
System: Vascular
Inclusion in quiz mode: Included

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