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European Radiology
Published in: European Radiology 6/2013

01-06-2013 | Ultrasound

Evaluation of distal turbulence intensity for the detection of both plaque ulceration and stenosis grade in the carotid bifurcation using clinical Doppler ultrasound

Authors: Emily Y. Wong, Hristo N. Nikolov, Richard N. Rankin, David W. Holdsworth, Tamie L. Poepping

Published in: European Radiology | Issue 6/2013

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Abstract

Objectives

To determine the interrelationship of stenosis grade and ulceration with distal turbulence intensity (TI) in the carotid bifurcation measured using conventional clinical Doppler ultrasound (DUS) in vitro, in order to establish the feasibility of TI as a diagnostic parameter for plaque ulceration.

Methods

DUS TI was evaluated in a matched set of ulcerated and smooth-walled carotid bifurcation phantoms with various stenosis severities (30, 50, 60 and 70 %), where the ulcerated models incorporated a type 3 ulceration.

Results

Post-stenotic TI was significantly elevated owing to ulceration in the mild and moderate stenoses (P < 0.001). TI increased with stenosis severity in both the ulcerated and non-ulcerated series, with a statistically significant effect of increasing stenosis severity (P < 0.001). Whereas TI in the mild and non-ulcerated moderate stenoses was less than 20.4 ± 1.3 cm s−1, TI in the ulcerated moderate and severe models was higher than 25.6 ±1.3 cm s−1, indicating a potential diagnostic threshold.

Conclusion

We report a two-curve relationship of stenosis grade and ulceration to distal TI measured using clinical DUS in vitro. Clinical DUS measurement of distal TI may be a diagnostic approach to detecting ulceration in the mild and moderately stenosed carotid artery.

Key Points

• Patients with carotid artery plaque ulcerations are at higher risk of stroke.
• Clinical Doppler ultrasound is routinely used to detect carotid artery stenosis.
• Doppler ultrasound turbulence intensity can detect ulceration in realistic flow models.
• Turbulence intensity also increases with stenosis severity independent of ulceration.
• Doppler ultrasound should help in assessing both stenosis severity and ulceration.
Literature
1.
Hankey GJ (1999) Stroke prediction and prevention by carotid endarterectomy: keep an eye on the doughnut and not just the hole. Cerebrovasc Dis 9:345–350PubMedCrossRef
2.
Eliasziw M, Streifler JY, Fox AJ et al (1994) Significance of plaque ulceration in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial. Stroke 25:304–308PubMedCrossRef
3.
Rothwell PM, Gibson R, Warlow CP (2000) Interrelation between plaque surface morphology and degree of stenosis on carotid angiograms and the risk of ischemic stroke in patients with symptomatic carotid stenosis. On behalf of the European Carotid Surgery Trialists’ Collaborative Group. Stroke 31:615–621PubMedCrossRef
4.
Prabhakaran S, Rundek T, Ramas R et al (2006) Carotid plaque surface irregularity predicts ischemic stroke: the northern Manhattan study. Stroke 37:2696–2701PubMedCrossRef
5.
Rothwell PM, Gutnikov SA, Warlow CP (2003) Reanalysis of the final results of the European Carotid Surgery Trial. Stroke 34:514–523PubMedCrossRef
6.
Wong EY, Nikolov HN, Thorne ML et al (2009) Clinical Doppler ultrasound for the assessment of plaque ulceration in the stenosed carotid bifurcation by detection of distal turbulence intensity: a matched model study. Eur Radiol 19:2739–2749PubMedCrossRef
7.
Stein PD, Sabbah HN (1974) Measured turbulence and its effect on thrombus formation. Circ Res 35:608–614PubMedCrossRef
8.
Cloutier G, Shung KK (1993) Study of red cell aggregation in pulsatile flow from ultrasonic Doppler power measurements. Biorheology 30:443–461PubMed
9.
Fox AJ (1993) How to measure carotid stenosis. Radiology 186:316–318PubMed
10.
Smith RF, Rutt BK, Fox AJ et al (1996) Geometric characterization of stenosed human carotid arteries. Acad Radiol 3:898–911PubMedCrossRef
11.
Wong EY, Thorne ML, Nikolov HN et al (2008) Doppler ultrasound compatible plastic material for use in rigid flow models. Ultrasound Med Biol 34:1846–1856PubMedCrossRef
12.
Lovett JK, Gallagher PJ, Hands LJ et al (2004) Histological correlates of carotid plaque surface morphology on lumen contrast imaging. Circulation 110:2190–2197PubMedCrossRef
13.
de Weert TT, Cretier S, Groen HC et al (2009) Atherosclerotic plaque surface morphology in the carotid bifurcation assessed with multidetector computed tomography angiography. Stroke 40:1334–1340PubMedCrossRef
14.
Ramnarine KV, Nassiri DK, Hoskins PR et al (1998) Validation of a new blood-mimicking fluid for use in Doppler flow test objects. Ultrasound Med Biol 24:451–459PubMedCrossRef
15.
Thorne ML, Poepping TL, Rankin RN et al (2008) Use of an ultrasound blood-mimicking fluid for Doppler investigations of turbulence in vitro. Ultrasound Med Biol 34:1163–1173PubMedCrossRef
16.
Holdsworth DW, Norley CJ, Frayne R et al (1999) Characterization of common carotid artery blood-flow waveforms in normal human subjects. Physiol Meas 20:219–240PubMedCrossRef
17.
Frayne R, Holdsworth DW, Gowman LM et al (1992) Computer-controlled flow simulator for MR flow studies. J Magn Reson Imaging 2:605–612PubMedCrossRef
18.
Poepping TL, Nikolov HN, Rankin RN et al (2002) An in vitro system for Doppler ultrasound flow studies in the stenosed carotid artery bifurcation. Ultrasound Med Biol 28:495–506PubMedCrossRef
19.
Hinze JO (1959) Turbulence: an introduction to its mechanism and theory. McGraw-Hill, New York
20.
Yongchareon W, Young DF (1979) Initiation of turbulence in models of arterial stenoses. J Biomech 12:185–196PubMedCrossRef
21.
Tamura T, Fronek A (1990) Detection of moving flow separation in pulsatile flow and the degree of stenosis by power of Doppler shift signals. Circ Res 67:166–174PubMedCrossRef
22.
Loree HM, Kamm RD, Atkinson CM et al (1991) Turbulent pressure fluctuations on surface of model vascular stenoses. Am J Physiol 261:H644–H650PubMed
23.
Hutchison KJ, Karpinski E (1985) In vivo demonstration of flow recirculation and turbulence downstream of graded stenoses in canine arteries. J Biomech 18:285–296PubMedCrossRef
24.
Hjortdal JO, Pedersen EM, Hjortdal VE et al (1991) Velocity field studies at surgically imposed arterial stenoses on the abdominal aorta in pigs. J Biomech 24:1081–1093PubMedCrossRef
25.
Nygaard H, Hasenkam JM, Pedersen EM et al (1994) A new perivascular multi-element pulsed Doppler ultrasound system for in vivo studies of velocity fields and turbulent stresses in large vessels. Med Biol Eng Comput 32:55–62PubMedCrossRef
26.
Solzbach U, Wollschlager H, Zeiher A et al (1987) Effect of stenotic geometry on flow behaviour across stenotic models. Med Biol Eng Comput 25:543–550PubMedCrossRef
27.
Young DF (1979) Fluid mechanics of arterial stenoses. J Biomech Eng 101:157–175CrossRef
28.
Ojha M, Cobbold RSC, Johnston KW et al (1989) Pulsatile flow through constricted tubes: an experimental investigation using photochromic tracer methods. J Fluid Mech 203:173–197CrossRef
29.
Casty M, Giddens DP (1984) 25 + 1 channel pulsed ultrasound Doppler velocity meter for quantitative flow measurements and turbulence analysis. Ultrasound Med Biol 10:161–172PubMedCrossRef
30.
Isaaz K, Bruntz JF, Da Costa A et al (2003) Noninvasive quantitation of blood flow turbulence in patients with aortic valve disease using online digital computer analysis of Doppler velocity data. J Am Soc Echocardiogr 16:965–974PubMedCrossRef
31.
Thorne ML, Rankin RN, Steinman DA et al (2010) In vivo Doppler ultrasound quantification of turbulence intensity using a high-pass frequency filter method. Ultrasound Med Biol 36:761–771PubMedCrossRef
32.
Thorne ML, Poepping TL, Nikolov HN et al (2009) In vitro Doppler ultrasound investigation of turbulence intensity in pulsatile flow with simulated cardiac variability. Ultrasound Med Biol 35:120–128PubMedCrossRef
33.
Grant EG, Benson CB, Moneta GL et al (2003) Carotid artery stenosis: grayscale and Doppler ultrasound diagnosis—Society of Radiologists in Ultrasound consensus conference. Ultrasound Q 19:190–198PubMedCrossRef
34.
Dunmire B, Pagel G, Beach KW et al. (2001) Post stenotic flow disturbances in a steady flow model. Proc SPIE 4325:502–513. doi:10.​1117/​12.​495782
35.
Evans DH, McDicken WN (2000) Doppler ultrasound: physics, instrumentation and signal processing, 2nd edn. Wiley, Chichester
36.
Cloutier G, Allard L, Durand LG (1996) Characterization of blood flow turbulence with pulsed-wave and power Doppler ultrasound imaging. J Biomech Eng 118:318–325PubMedCrossRef
37.
Ojha M, Johnston KW, Cobbold RS et al (1989) Potential limitations of center-line pulsed Doppler recordings: an in vitro flow visualization study. J Vasc Surg 9:515–520PubMed
38.
Haberman S, Friedman Z (1998) Multigated simultaneous spectral Doppler imaging: a new ultrasound modality. Obstet Gynecol 92:299–302PubMedCrossRef
39.
Tortoli P, Bassi L, Boni E et al (2009) ULA-OP: an advanced open platform for ultrasound research. IEEE Trans Ultrason Ferroelectr Freq Control 56:2207–2216PubMedCrossRef
40.
Imbesi SG, Kerber CW (1998) Why do ulcerated atherosclerotic carotid artery plaques embolize? A flow dynamics study. AJNR Am J Neuroradiol 19:761–766PubMed
41.
Giannattasio C, Mancia G (2002) Arterial distensibility in humans. Modulating mechanisms, alterations in diseases and effects of treatment. J Hypertens 20:1889–1899PubMedCrossRef
42.
Benetos A, Waeber B, Izzo J et al (2002) Influence of age, risk factors, and cardiovascular and renal disease on arterial stiffness: clinical applications. Am J Hypertens 15:1101–1108PubMedCrossRef
43.
Van Bortel LM, Spek JJ (1998) Influence of aging on arterial compliance. J Hum Hypertens 12:583–586PubMedCrossRef
44.
Mancia G, Giannattasio C, Grassi G (1998) Arterial distensibility in cardiovascular diseases. J Nephrol 11:284–288PubMed
45.
Hansen F, Mangell P, Sonesson B et al (1995) Diameter and compliance in the human common carotid artery–variations with age and sex. Ultrasound Med Biol 21:1–9PubMedCrossRef
46.
Perktold K, Rappitsch G (1995) Computer simulation of local blood flow and vessel mechanics in a compliant carotid artery bifurcation model. J Biomech 28:845–856PubMedCrossRef
47.
Zhao SZ, Xu XY, Hughes AD et al (2000) Blood flow and vessel mechanics in a physiologically realistic model of a human carotid arterial bifurcation. J Biomech 33:975–984PubMedCrossRef
48.
Rundek T (2007) Beyond percent stenosis: carotid plaque surface irregularity and risk of stroke. Int J Stroke 2:169–171PubMedCrossRef
49.
Ahmed RM, Harris JP, Anderson CS et al (2010) Carotid endarterectomy for symptomatic, but “haemodynamically insignificant” carotid stenosis. Eur J Vasc Endovasc Surg 40:475–482PubMedCrossRef
50.
Saba L, Caddeo G, Sanfilippo R, Montisci R, Mallarini G (2007) CT and ultrasound in the study of ulcerated carotid plaque compared with surgical results: potentialities and advantages of multidetector row CT angiography. AJNR Am J Neuroradiol 28:1061–1066PubMedCrossRef
51.
Remonda L, Senn P, Barth A, Arnold M, Lovblad KO et al (2002) Contrast-enhanced 3D MR angiography of the carotid artery: comparison with conventional digital subtraction angiography. AJNR Am J Neuroradiol 23:213–219PubMed
52.
Nesbitt WS, Westein E, Tovar-Lopez FJ et al (2009) A shear gradient-dependent platelet aggregation mechanism drives thrombus formation. Nat Med 15:665–673PubMedCrossRef
Metadata
Title
Evaluation of distal turbulence intensity for the detection of both plaque ulceration and stenosis grade in the carotid bifurcation using clinical Doppler ultrasound
Authors
Emily Y. Wong
Hristo N. Nikolov
Richard N. Rankin
David W. Holdsworth
Tamie L. Poepping
Publication date
01-06-2013
Publisher
Springer-Verlag
Published in
European Radiology / Issue 6/2013
Print ISSN: 0938-7994
Electronic ISSN: 1432-1084
DOI
https://doi.org/10.1007/s00330-012-2741-6

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