ULTRASONOGRAFIA ULTRASONOGRAFIA CAROTIDIANACAROTIDIANA

Alexandru AndritoiuAlexandru Andritoiu,, MD MD

Sp. Militar Clinic de Urgenta CraiovaSp. Militar Clinic de Urgenta CraiovaESC, EAS, Artery Research

SistemulSistemul carotidiancarotidian(extra(extra--craniancranian))

(A) (B)

Variante geometrice Variante geometrice ale ale bifurcatieibifurcatiei carotidienecarotidiene

PoligonulPoligonul WillisWillis

Henri Marie Coanda Henri Marie Coanda (1886–1972)(1886–1972)

,,Coanda effect or wall-attachment effect (1930) - the tendency of a moving fluid, either liquid or gas, to attach itself to a surface and flow along it,,

Principiul BernoulliPrincipiul Bernoulli

In fluid dynamics, In fluid dynamics, Bernoulli's Bernoulli's principleprinciple states that for a flow, an  states that for a flow, an increase in the speed of the fluid occurs increase in the speed of the fluid occurs simultaneously with a decrease simultaneously with a decrease in pressure or a decrease in in pressure or a decrease in the fluid's potential energy.the fluid's potential energy.

Bernoulli's principle is named after Bernoulli's principle is named after the Dutch-Swiss mathematician Daniel the Dutch-Swiss mathematician Daniel Bernoulli who published his principle in his Bernoulli who published his principle in his book book HydrodynamicaHydrodynamica in 1738.  in 1738.

Tehnici de examinare Tehnici de examinare USUS ANATOMICEANATOMICE B-modB-mod PanoramicaPanoramica 3D3D IVUSIVUS CEUSCEUS

HEMODINAMICEHEMODINAMICE B-flowB-flow Sie-flowSie-flow Doppler spectralDoppler spectral AngioAngio CEUSCEUS TDITDI

SetariSetari

BB--modmod

GaineGaine

DGCDGC

DepthDepth

PowerPower

Dynamic rangeDynamic range

Focus Focus

DOPPLERDOPPLER

PRF (meanPRF (mean--high)high)

ColorColor--boxbox

SteerSteer

BaseBase--lineline

SyncroneSyncrone

Gate Gate

Scale Scale

Angle <60 Angle <60 grgr

B-modB-mod

Sectiune in axul lung Sectiune in ax transversal

ACC

ACI

ACE

Doppler spectralDoppler spectral

Indicii spectraliIndicii spectrali

Valorile de referinta ale parametrilor Doppler Valorile de referinta ale parametrilor Doppler spectral pentru segmentul extracranian al spectral pentru segmentul extracranian al arterelor carotidearterelor carotide

ACCACI

proximalaACI

distala

Vmax S (cm/s) 59 57 65

Vmin D (cm/s) 15 22 27

Legenda: Analiza a fost efectuata pe un lot de subiecti potriviti ca varsta si sex:

21-40 ani (N=46), 41-60 (N=56), >60 ani (N=56). Pentru sexul feminin s-au remarcat valori mai mari ale

velocitatilor in ACI, dar nu si in ACC. Andritoiu A 2009

IR - VarstaIR - Varsta

0,790,76

0,740,720,72

0,6

0,65

0,7

0,75

0,8

0,85

40-49 50-59 60-69 70-79 80-89

Ani

IR

N = 405; varsta 40-90 ani

Andritoiu A 2009

Diametrul carotidianDiametrul carotidian

6,375,89

1

2

3

4

5

6

7

Dia

met

rul A

CC

(m

m)

B

F

Diametrul mediu al ACC masurat la un lot de 405 subiecti cu varsta intre 40-85 ani (237 B si 168 F)

Diametrul mediu in grupul barbatilor a fost de 6.37+/-0.7 mm, iar in cel al femeilor de 5.89+/-0.6 mm (p<0.01). Varsta medie a celor doua grupuri nu a fost diferita statistic.

Andritoiu A 2009

(1) diametrul si grosimea medio-intimala normale, (2) ingrosare izolata a complexului intima-medie, (3) cresterea izolata a diametrului arterial, (4) cresterea in dimensiuni atat a diametrului cat si a

complexului intima-medie.

Fenotipuri arterialeFenotipuri arteriale

Eigenbrodt ML 2008

25 23

38

58

75

0

20

40

60

80

4-4,9 5-5,9 6-6,9 7-7,9 8-8,9

Diametrul ACC (mm)

% P

laci

lor

Relatia D – Frecv. Placi ATSRelatia D – Frecv. Placi ATS

Rezultate obtinute prin evaluarea ultrasonografica a unui lot de 405 subiecti cu varsta cuprinsa intre 40-85 ani.

Andritoiu A 2009

CIMTCIMT

CIMTCIMT

.

Carallo C et al. Hypertension 1999;34:217-221

Relatia CIMT - mean wall shear stress (relatie directa)

.

Carallo C et al. Hypertension 1999;34:217-221

Relatia CIMT - mean circumferential wall tension (relatie inversa)

CIMTCIMT

Masuratori manualeMasuratori manuale Masuratori Masuratori

automateautomate

VN <0.9 mm

MMaasursurareaarea CIMT CIMT prin ecografie in mod prin ecografie in mod BBExExeemplmpluu de la unde la un sub subiiect ect din studiuldin studiul METEOR METEOR

Detaliu aratand masurarea CIMTImagine ecografica a arterei carotide

CIMT - CEUSCIMT - CEUS

CIMT –Marker de risc CIMT –Marker de risc C-VC-V

Scorul de risc (Framingham, Scorul de risc (Framingham, SCORE)SCORE)

Boala coronariana ischemicaBoala coronariana ischemica Sdr. metabolicSdr. metabolic Arteriopatia obliterantaArteriopatia obliteranta Disfunctia endoteliala Disfunctia endoteliala

(%FMD)(%FMD) Markerii de inflamatie (hs Markerii de inflamatie (hs

CRP)CRP)

Studiul ARIC Studiul ARIC Studiul Rotterdam Studiul Rotterdam Cardiovascular Cardiovascular

Health StudyHealth Study

Volume 340:14-22 January 7, 1999 Number 1

Carotid-Artery Intima and Media Thickness as a Risk Factor for Myocardial Infarction and Stroke in Older Adults

Daniel H. O'Leary, M.D., Joseph F. Polak, M.D., M.P.H., Richard A. Kronmal, Ph.D., Teri A. Manolio, M.D., M.H.S., Gregory L. Burke, M.D., M.S., Sidney K. Wolfson, M.D., for The Cardiovascular

Health Study Collaborative Research Group

Incidence of Myocardial Infarction or Stroke According to Quintile of Carotid-Artery Intima–Media Thickness.

IMT in subjects with and without clinical atherosclerosis.

Hashimoto M et al. Arteriosclerosis, Thrombosis, and Vascular Biology. 1999

CIMT – genetica HDL CIMT – genetica HDL

Relatia CIMT - varstaRelatia CIMT - varsta

0

0,2

0,4

0,6

0,8

40-49 50-59 60-69 70-79 80-89

Ani

CIM

(m

m)

N = 405 subiecti; varsta 40-90ani

Andritoiu A 2009

CIMT sex M > CIMT sex CIMT sex M > CIMT sex FF

0,42

0,44

0,46

0,48

0,5

0,52

0,54

CIM

(m

m)

B F

p<0.01

N = 405 subiecti; 237 B – 168 Fvarsta 40-90 ani

Andritoiu A 2009

Relatia dintre grosimea Relatia dintre grosimea CIM CIM si prezenta placilor ATS si prezenta placilor ATS

0,44

0,63

0

0,2

0,4

0,6

0,8

Placa Non-Placa

r = 0.40; p<0.0001; IC95% 0.281-0.514

N = 405 subiecti; varsta 40-90 ani

Andritoiu A 2009

Influenta CIM asupra IR este Influenta CIM asupra IR este semnificativa statistic semnificativa statistic

r = 0.21, p = 0.03 r = 0.21, p = 0.03

((ICIC 95%95%;; 0.073-0.338) 0.073-0.338)

Andritoiu A 2009

PLACA DE ATEROMPLACA DE ATEROM

Prevalenta placilor Prevalenta placilor carotidienecarotidiene

Pacienti cu placa;

515; 40%Pac. fara

placa; 780; 60%

N = 1295 subiecti; 40-90 ani; B 720: F 575

Andritoiu A, nepubl.

Prevalenta placilor ATS Prevalenta placilor ATS pe decade de varstape decade de varsta

13,7928,35

43,857,14

81,25

0

20

40

60

80

100

40-49 50-59 60-69 70-79 80-89

Ani

Pre

vale

nta

%

N =405; 40-90 ani

Andritoiu A 2009

Aspecte Aspecte

Placi nodularePlaci nodulare Placi parietalePlaci parietale

Placa ,,in musuroi,,Placa ,,in musuroi,,

Aria placii de ateromAria placii de aterom

Volumul placiiVolumul placii

Reconstructie 3DReconstructie 3D

Ecogenitatea Ecogenitatea

Anecogena Anecogena Hipoecogena Hipoecogena EcogenaEcogena HiperecogenaHiperecogena Hiperecogena cu con de umbra (Ca++)Hiperecogena cu con de umbra (Ca++)

REPERE• Lumenul vascular• Mm SCM• Adventicea (apofiza traversa)

Placa vulnerabilaPlaca vulnerabila

Placa instabila Placa instabila (,,la (,,la risc,,)risc,,)

Capison subtireCapison subtire Suprafata ulcerataSuprafata ulcerata Miez lipidicMiez lipidic Hipo/anecogenaHipo/anecogena

Analiza histografica a Analiza histografica a placiiplacii

Reconstructie 3D Reconstructie 3D distributia Gray-scale distributia Gray-scale valuevalue

Elastografia placii?Elastografia placii?

NU! Doar Adobe Photoshop!!!!

Mapping color Mapping color ((Adobe PhotoshopAdobe Photoshop))

Adobe Photoshop – Gradient Map

ROI - Gradient Map

Relation between plaque characteristics and primary outcome.

Hellings W E et al. Circulation 2010;121:1941-1950

Mecanismele Mecanismele neoangiogenezei neoangiogenezei

Neovascularizatia Neovascularizatia placiiplacii

Feinstein SB - JACC 2006

Neovascularizatia Neovascularizatia placii -CEUSplacii -CEUS

Staub D - Stroke 2010

Coli S. et al. J Am Coll Cardiol 2008;52:223-230

Vessel Density at Histology According to Plaque Contrast-Agent Enhancement

Coli S. et al. J Am Coll Cardiol 2008;52:223-230

Hypoechoic Carotid Plaque With Extensive (Grade 2) Contrast-Agent Enhancement

Relatia dintre Relatia dintre neovascularizatie si neovascularizatie si instabilitatea placiiinstabilitatea placii

Matsumoto N 2010

Coli S. et al. J Am Coll Cardiol 2008;52:223-230

Plaque Without Contrast-Agent Enhancement Showing Scant Neovascularization at

Histology

Coli S. et al. J Am Coll Cardiol 2008;52:223-230

Plaque With Grade 2 Contrast-Agent Enhancement Showing Abundant Neovascularization at Histology

Coli S. et al. J Am Coll Cardiol 2008;52:223-230

Grade of Contrast-Agent Enhancement According to Plaque Echogenicity

Neovascularizatia Neovascularizatia placii si riscul C-Vplacii si riscul C-V

Staub D - Stroke 2010

Placa ulcerataPlaca ulcerata

CEUS – ulceratia placiiCEUS – ulceratia placii

Feinstein SB - JACC 2006

STENOZA STENOZA CAROTIDIANACAROTIDIANA

15

6

stenoza ocluzie

Prevalenta stenozei si Prevalenta stenozei si ocluziei carotidieneocluziei carotidiene

1.15/1000

0.46/1000

Andritoiu A, nepubl.

N = 1295 subiecti; 40-90 ani; B 720: F 575

CalcululCalculul stenozeistenozei((angiograficangiografic))

d

NASCET vs ECST vs CC

Calculul angiografic al Calculul angiografic al stenozei carotidienestenozei carotidiene

NASCET vs ESCTNASCET vs ESCT

Metoda americanaMetoda americana(NASCET, ACAS)(NASCET, ACAS)

Metoda europeana Metoda europeana ESCTESCT

30%30%40%40%50%50%60%60%70%70%80%80%90%90%

65%65%70%70%75%75%80%80%85%85%91%91%97%97%

Stenoza ACI - Doppler Stenoza ACI - Doppler colorcolor

METODELE METODELE PLANIMETRICEPLANIMETRICE

% D% A

% Stenozei% Stenozei PSV(cm/s)PSV(cm/s) EDV (cm/s)EDV (cm/s) PSV ACI/PSV PSV ACI/PSV ACCACC

<50<50 <150<150 <50<50 <1.8<1.8

50-7050-70 150-250150-250 50-9050-90 1.8-2.81.8-2.8

70-90 70-90 250-400250-400 90-15090-150 2.8-52.8-5

90-9990-99 >400>400 >150>150 >5>5

METODELE METODELE VELOCIMETRICEVELOCIMETRICE

RelatiaRelatia MeanVMeanV RatioRatio--AngiografieAngiografie

3D Power3D Power--angioangio

Wessels T- Stroke 2004

Stenoza severa (asimptomatica) de ACI la un pacient in varsta de 68 ani. Examinarea Doppler color evidentiaza flux stenotic, cu aliasing color. Planimetric (%D), stenoza este apreciata la 77% - metoda europeana ESCT. Diametrul lumenului stenozei este de aproximativ 1.5 mm. Examinarea power-angio evidentiaza tendinta de stenoza preocluziva, cu efilarea zonei de culoare. In modul spectral, PSV este estimata la 260 cm/s.

CuantificareaCuantificarea stenozeistenozeicarotidienecarotidiene prinprin IVUSIVUS

GhiduriGhiduri

2003-The Society of 2003-The Society of Radiologists in Ultrasound Radiologists in Ultrasound ConsensusConsensus

2008- Joint Recommendation 2008- Joint Recommendation for Reporting Carotid for Reporting Carotid Ultrasound Investigations in Ultrasound Investigations in the United Kingdomthe United Kingdom

Gradarea US a stenozei Gradarea US a stenozei ACIACI

Gradul stenozei Gradul stenozei (%)(%)

PSV ACI PSV ACI (cm/s)(cm/s)

Raport PSVRaport PSV

NormalNormal <125<125 <2<2

<50<50 <125<125 <2<2

50-6950-69 125-230125-230 2-42-4

>70-90>70-90 >230>230 >4>4

PreocluziePreocluzie VariabilVariabil VariabilVariabil

OcluzieOcluzie NedetectabilNedetectabil NedetectabilNedetectabil

Society of Radiologists in Ultrasound; Grant EG et al- Radiology 2003;229:340-346)

Dr. Eugene StrandnessUniversity of Washington

Normal = no plaque, no turbulence PSV <125 cm/sec 1-15 % stenosis = minimal plaque, PSV < 125 cm/sec 16-49 % stenosis = moderate plaque, mild spectral

broadening throughout systole, PSV < 125 cm/second 50-79 % stenosis = PSV > 125 cm/second, greater

spectral broadening throughout systole, heavier, more prominent plaque

formation present. 80-99% stenosis = PSV > 125 cm/sec, marked spectral broadening and turbulence, severe plaque formation,

and end diastolic velocity elevated > 140cm/second occlusion

Ocluzie ACI dr.Ocluzie ACI dr.Stenoza contra-laterala Stenoza contra-laterala stgstg

Arterita TakayasuArterita Takayasu

Algoritm de managemnet al Algoritm de managemnet al stenozei carotidienestenozei carotidiene

American Heart Association & National Stroke Association

= +

STENOZA CAROTIDIANA >60% (N=197)

12%

66%

34%Stenoza >60% - AIT/AVC

Lez carotidiene – deficit motor

RelatiaRelatia StenozaStenoza /AIT/AIT--AVCAVC

Andritoiu A-2009

Frecventa stenozei carotidiene (>60%), masurata planimetric prin ultrasonografie, la un lot de 197

pacienti spitalizati pentru AVC ischemic

Riscul major al Riscul major al stenozei carotidienestenozei carotidiene

Infarct cerebral (stroke) Infarct cerebral (stroke) homolateral pentru stenoza homolateral pentru stenoza simptomaticasimptomatica

Deces de cauza cardiaca pentru Deces de cauza cardiaca pentru stenoza asimptomaticastenoza asimptomatica

OCLUZIA CAROTIDIANAOCLUZIA CAROTIDIANA

OcluzieOcluzie de ACI de ACI ((angiografieangiografie standard)standard)

ColateraleleColateralele din din ocluziaocluzia ACIACI

Rutgers DR et al. Stroke 2000

TipurileTipurile hemodinamicehemodinamiceintraintra--orbitareorbitare @n @n ocluziaocluzia ACIACI

Yamamoto T- Br J Ophthalmol 2004

Ocluzie ACI - CEUSOcluzie ACI - CEUS

Manifestari alegodermitice dupa administrarea de SonoVue, la un pacient in varsta de 40 ani, cu teren atopic (alergie la Penicilina). Reactia alergica s-a manifestat tardiv (la peste 8 ore de la injectare) cu elemente cutanate de tip urticarian, insotite de prurit intens, tumefactia extremitatilor si fotosensibilizare, ce s-au remis lent dupa administrare de cortizon si antihistaminice (colectia Dr. Andritoiu A)

Ligatura ACILigatura ACI

Ligatura ACELigatura ACE

Preocluzia ACIPreocluzia ACI

FFF utile! Examinarea ACI distala / trans-orala

Falsa ocluzieFalsa ocluzie

A oftalmicaA oftalmica

ACM homolateralaACM homolaterala

Debitul cerebralDebitul cerebral

Q cer = Q ACI dr + Q ACI stg + Q AV dr + Q AV stg

Q = TAV x A

Varsta (ani) 20-39 40-59 60-85

Q cerebral (mL/min) 727+/-102 656+/-121 603+/-106

Scheel P - Stroke 2000

QCG in stenoza QCG in stenoza carotidianacarotidiana

532+/-89

224+/-89

Stenozaasimptomatica

Stenozasimptomatica

QC

G (

mL/

min

)

Lam WWM - J Ultrasound Med 2003

Angioplastia Angioplastia vs vs EndarterectomiaEndarterectomia

Endarterectomia Endarterectomia

US intraUS intra--operatorieoperatorie

Stenturi carotidieneStenturi carotidiene

ParametriiParametrii spectralispectrali aiaistentuluistentului carotidiancarotidian

77+/-4

25+/-2

70+/-3

17+/-1

90+/-4

26+/-2

86+/-5

24+/-2

92+/-6

24+/-2

PSV (cm/s)

EDV (cm/s)

Kupinski AM. J Vasc Ultrasound 2004

Restenoza post Restenoza post endarterectomieendarterectomie

Restenoza post Restenoza post stentarestentare

Limitele cut-off propuse Limitele cut-off propuse pentru restenoza intra-pentru restenoza intra-stentstent

RestenozRestenozaa PSV (cm/s)PSV (cm/s) ACI/ACCACI/ACC

50-69%50-69% 240240 2.452.45

>70%>70% 450450 4.34.3

Chi Y-W - Catheterization and Cardiovascular Interventions 2007

Rezultatele terapiei Rezultatele terapiei hipolipemiante in regresia hipolipemiante in regresia ATSATS

Reducerea LDL Col Regresia Reducerea LDL Col Regresia CIMTCIMT

Timp (ani)

Mod

ifica

rea

IMT

la c

ele

12

nive

le d

in c

arot

ide

(m

m)

-0,01

+0,01

0,00

+0,02

21

+0,03

Pro

gre

sie

Reg

resi

e

P=NS(CRESTOR vs. curba zero)

Placebo+0,0131 mm/an

(n=252)

Rosuvastatin 40 mg-0,0014 mm/an

(n=624)

P<0,0001 (CRESTOR vs. placebo)

Placebo; Modificarea CIMT (95% CI)

Rosuvastatin 40 mg; Modificarea CIMT (95% CI)

METEOR METEOR ModificareaModificarea IMT IMT maxim la celemaxim la cele 12 12 nivele din nivele din

carotidcarotidee (Rosuvastatin vs placebo) (Rosuvastatin vs placebo)

Crouse JR, et al. JAMA 2007;297;12:1344-53

Ainsworth CD - Stroke 2005

Reducerea volumului placii sub terapia Reducerea volumului placii sub terapia

cu Atorvastatin 80 mg/zi – evaluare la 3 lunicu Atorvastatin 80 mg/zi – evaluare la 3 luni

Studii de fiziologieStudii de fiziologie

CompliantaComplianta DistensibilitateaDistensibilitatea Modulul de Modulul de

elasticitateelasticitate

Haluska et al. Cardiovascular Ultrasound 2007

Distensibilitatea ACIDistensibilitatea ACI

Mancia G et al. Hypertension 2001

Cinetica peretelui Cinetica peretelui carotidian carotidian si a placiisi a placii (AWM) (AWM) TDITDI

Ramnarine et al. Cardiovascular Ultrasound 2003

Ramnarine et al. Cardiovascular Ultrasound 2003

PWVPWV

Calabia et al. Cardiovascular Ultrasound 2011

ABC-ul US carotidiene

A = anatomieIdentificarea vaselor este corecta?Cat de bine este vizualizata bifurcatia ?

B = B-modeCauta placile pe axul ACC, ACI (omogene/heterogene)

C = ColorSe vizualizeaza stenoza?Stenoza <60% se estimeaza planimetric!

D = Doppler spectralVelocitatile ACI sunt concordante cu estimarea planimetrica a stenozei?

Message take homeMessage take home