1. Carotid Dissection An Actual Case from: Detroit Medical Center, Harper University Hospital Vascular Lab Presented By : Angela Bowling Baker College Of Auburn Hills Vascular Ultrasound Winter, 2013

2. Overview Carotid Dissection: Description Typical Symptoms Treatment Statistics Patient Information: Demographics Symptoms History Test Ordered Images: Waveform Interpretation Hemodynamics B-Mode Preliminary Report Conclusion

3. Carotid Dissection “Hemorrhage within the carotid wall” Trauma or Spontaneous Intima tears Dissecting the carotid artery into two parts “True Lumen” Usually crowded by false lumen “False Lumen” Can be patent or thrombosed Waveforms typically to/fro flow in false lumen. Rumwell & McPharlin, (2009), Zwiebel & Pellerito, (2005). www.ispub.com, (2012

4. Carotid Dissection Typical Symptoms: Horner syndrome, (drooping eyelid, decreased pupil size) “Neck pain, headache, tinnitus, transient monocular blindness” Asymptomatic Treatment: Anticoagulation Surgical Stent Zwiebel & Pellerito, (2005) Rumwell & McPharlin, (2009)

5. Carotid Dissection RARE: In United States: only 2.6 per 100,000 patients. How many in this room have scanned a Carotid Dissection? Detroit Medical Center, (2012), Zwiebel & Pellerito, (2005).

6. Patient Information Initials: MJ Sex: Female Age: 80 years old Symptoms: Syncope History: Prior Carotid Aneurysm with Corrective Surgery Recent Fall down 2 steps due to syncope Test Ordered: Bilateral Carotid Study Detroit Medical Center, (2012).

7. Images: Waveforms. Rumwell & McPharlin, (2009), Detroit Medical Center, (2012), Zwiebel & Pellerito, (2005).

8. Images: Waveforms Rumwell & McPharlin, (2009), Detroit Medical Center, (2012), Zwiebel & Pellerito, (2005).

9. Images: Waveforms Rumwell & McPharlin, (2009), Detroit Medical Center, (2012), Zwiebel & Pellerito, (2005).

10. Images: Hemodynamics Rumwell & McPharlin, (2009), Detroit Medical Center, (2012), Zwiebel & Pellerito, (2005).

11. Images: Hemodynamics Rumwell & McPharlin, (2009), Detroit Medical Center, (2012), Zwiebel & Pellerito, (2005).

12. Images: B-Mode Rumwell & McPharlin, (2009), Detroit Medical Center, (2012), Zwiebel & Pellerito, (2005).

13. Preliminary Report Vascular Lab Report Indication: Syncope On the right: Smooth dense plaque visualized in ICA, PSV of ICA was 74 cm/sec ESV of 26cm/sec B-mode images and velocities are consistent with 1-39% diameter reduction of the proximal internal carotid artery. Right Brachial Systolic: 124 mmHg Left Brachial Systolic: 120 mmHg Vertebral arteries: appeared to have ante grade flow bilaterally On the left: Irregular dense plaque visualized in ICA, PSV of ICA was 107cm/sec ESV of 27cm/sec B-mode images and velocities are consistent with 1-39% diameter reduction of the proximal internal carotid artery. Detroit Medical Center, (2012)

14. Preliminary Report Continued On the left, there was a dissection in the mid common carotid artery visualized. The velocities pre dissection were 68 cm/sec, and the velocities post dissection were 228 cm/sec. There was a clip that was shadowing out a partial area of the common carotid artery. Doctor was notified of the results. Detroit Medical Center, (2012)

15. Conclusion Patient: MJ, 80 year old female Symptom: Syncope History: Prior carotid aneurysm surgery Detroit Medical Center, (2012 ) Rumwell & McPharlin, (2009) Zwiebel and Pellerito, (2005) Detroit Medical Center, (2012)

16. Conclusion Waveform Interpretation: Pre-dissection: Laminar flow with spectral window intact Moderate pulsatility Normal PSV of 68 cm/sec False Lumen: Reversal of flow : below baseline Post-dissection: Turbulent flow with spectral window filled in Moderate pulsatility Suggested jet like PSV of 228 cm/sec Hemodynamics: Area of flow separation post dissection (Bernoulli Principle) Turbulent flow post dissection with mosaic patterns Retrograde flow in false lumen Detroit Medical Center, (2012) Zwiebel and Pellerito, (2005) Rumwell & McPharlin, (2009),

17. Conclusion B-Mode Images: Plaque visualized ICA Bilaterally Left Mid CCA Dissection and clip with shadow Suggested findings: Left Side Common Carotid Artery Dissection, Clip shadowing area of dissection. 1- 39% stenosis Bilaterally in ICA Treatment: Anticoagulation Detroit Medical Center, (2012)

18. References Internet Scientific Publications, ISPUB.com (2012), The Internet Journal of Neurosurgery (Volume 7 No. 2), www.ISPUB.com Rumwell, C. & McPharlin, M. (2009). Vascular technology: An illustrated review (4 th ed.). Pasadena, CA: Davies Publishing Zwiebel, W. & Pellerito, J, (2005). Introduction to vascular ultrasonography (5 th ed.). Philadelphia, PA: Elsevier Saunders