Perspectives in Medicine (2012) 1, 8285

Bartels E, Bartels S, Poppert H (Editors):

New Trends in Neurosonology and Cerebral Hemodynamics an Update.
Perspectives in Medicine (2012) 1, 8285

journal homepage: www.elsevier.com/locate/permed

Threedimensional imaging of carotid arteries:

Advantages and pitfalls of ultrasound investigations
Edoardo Vicenzini , Stefano Pro, Gaia Sirimarco, Patrizia Pulitano,
Oriano Mecarelli, Gian Luigi Lenzi, Vittorio Di Piero

Stroke Unit Neurosonology, Neurophysiology Unit, Department of Neurology and Psychiatry, Sapienza University of Rome, Italy

KEYWORDS Summary
Objectives: To describe normal and pathological ndings with three-dimensional (3D) ultrasound
3D ultrasound;
of the carotid bifurcation.
Carotid arteries
Methods: Patients admitted to our ultrasound laboratory for vascular screening were submitted
imaging;
to standard carotid duplex and to 3D ultrasound reconstruction of the carotid bifurcation.
Extracranial carotid
Volume 3D scans were performed manually, on the axial plane, and the software presented the
arteries tortuosity
volume rendering from the inward blood ow signal detected with the Power Color Mode.
and kinking;
Results: Forty normal subjects, 7 patients with caliber alterations (4 carotid bulb ectasia and 3
Carotid stenosis
internal carotid lumen narrowing), 45 patients with course variations (tortuosities and kinkings)
and 35 patients with internal carotid artery stenosis of various degrees have been investigated.
Conclusions: 3D ultrasound is a feasible technique. It can improve carotid axis general imaging
through a global image presentation at a glance, visualizing caliber variations and vessels
course. Imaging of stenosis from inward ow can be provided, but complete stenosis charac-
terization requires the assessment of plaque morphology and vessel wall.
2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

Introduction Recently we have published the possibility of 3D US bifurca-

Several specialists use three-dimensional (3D) ultrasound
(US) as adjuvant imaging technique in their clinical prac-
tice, from cardiologists to gynecologists [15]. The virtual
3D image presentation may be useful also for surgeons, to
better study anatomical boundaries of the structures to be
submitted to surgical procedures [6,7]. For carotid arteries,
it has been applied to study carotid plaque morphology, sur-
face and volume during atherosclerosis progression [813].
Corresponding author at: Department of Neurology and Psychi-
atry, Sapienza University of Rome, Viale dellUniversit 30, 00185
Rome, Italy. Tel.: +39 06 49914705; fax: +39 06 49914194.
E-mail address: edoardo.vicenzini@uniroma1.it (E. Vicenzini).
tion imaging in other conditions than carotid stenosis [14],
easily visualizing bifurcation anatomy changes of the caliber
and vessels course modications.
Materials and methods
Patients admitted to our US laboratory for vascular screen-
ing were submitted to standard carotid duplex and to 3D
US reconstruction of the carotid bifurcation. Forty normal
subjects, 7 patients with caliber alterations (4 carotid bulb
ectasia and 3 internal carotid lumen narrowing), 45 patients
with course variations (tortuosities and kinkings) and 35
patients with ICA stenosis of various degrees have been
investigated.

2211-968X 2012 Elsevier GmbH.Open access under CC BY-NC-ND license.

http://dx.doi.org/10.1016/j.permed.2012.03.005
Advantages and pitfalls of ultrasound investigations
Figure 1 US 3D reconstruction of normal bifurcation. IC:
internal carotid artery; EC: external carotid artery; BLB: carotid
bulb; CC: common carotid artery. Green arrow indicates the
superior thyroidal artery.
3D US data acquisition
The Siemens S2000 US system with high frequency linear
probes (9, 14 and 18 MHz) and proprietary 3D/4D reconstruc-
tion software (v 1.6) have been used.
3D volume scans were recorded manually. After xing the
proximal tract of the common carotid artery (CC) in the
center of the display in the transversal plane, a test axial
scanning was performed, from proximal CC to distal inter-
nal carotid artery (ICA) at approximately 1 cm per second
speed to adjust the visualization. The 3D ultrasound soft-
ware was then switched on to record the volume scan: the
Power box was set to the orthogonal 90 angle position; Pulse
Repetition Frequency (PRF), color gain and color persistence
were adjusted during a second test axial scan, in order to
reduce artifacts due to the inward ow color signal overlap-
ping the vessel wall and to minimize color ashing due
to the blood pulsatility. The features of the software axial
reconstruction and medium resolution that is set for
a length of 10 cm to be scanned in 12 s were selected.
Data acquisition was then started and stopped manually; a
bar control displayed on the screen the feedback for main-
taining a constant straight direction and scan velocity. At
the end of the scan, the 3D ultrasound volume render-
ing reconstruction of the acquired volume set was started
on the system. After the global 3D image presentation, B-
Mode imaging was excluded and Color Magnication (Color
Priority) adjusted to optimize the nal visualization of the
vessels.
Results
Visualization of the normal bifurcation
Threedimensional US reconstruction in normal subjects
allows a good visualization of the carotid bifurcation. In
Fig. 1 (Clip 1), an example is reported: all the extracranial
carotid arteries are easily identiable (CC: common carotid
artery; IC: internal carotid artery; EC: external carotid
83
Figure 2 US 3D reconstruction of carotid bulb ectasia.
artery; green arrow: superior thyroidal artery), with the
possibility of rotating the image through different planes.
Caliber variations
Carotid bulb ectasia
The vessel dilatation, characterized by a fusiform enlarge-
ment (usually 11.5 cm of antero-posterior diameter),
usually involving the distal tract of the common carotid
artery and extending through the bulb to the internal
carotid artery origin, can be easily recognized. Moreover,
the 3D reconstruction, rotating in the different planes,
allows a better global identication of the anatomy (Fig. 2).
However, the reconstruction images have always to be
considered with caution for nal diagnostic decisions, as
ow disturbances can cause several artifacts in the post-
processing image reconstruction: nal 3D pictures cannot be
considered alone and without the previous or concomitant
mandatory analysis of the bidimensional images.
Course variations tortuosities and kinkings
Extracranial vessels course abnormalities are frequent and
generally asymptomatic in the general population [15].
According to their angle in respect to the vessel, they can be
classied in tortuosities and kinkings, when changes
in the vessel course are greater than 90 . Even though these
alterations are asymptomatic and without clinical relevance
in the normal subject, tortuosities and kinkings have to be
identied prior to surgical procedures, since they may hin-
der for example the intravascular positioning of a stent,
while the anatomical approach and clamping of the internal
carotid artery may be easier during endarterectomy [16].
Bidimensional standard US imaging with Duplex, Color and
Power Doppler easily reveal the changes of the blood ow
direction according to the vessel direction change. While in
the bidimensional images it is usually necessary to repeat-
edly correct the color box insonation angle or to adjust
the probe orientation to obtaining optimal complete ves-
sel recognition, the 3D reconstruction can be of help to gain
the whole visualization at a glance [to view the gure,
please visit the online supplementary le].
84
Figure 3 US 3D reconstruction of moderate internal carotid
stenosis. Green dotted lines show plaque contour, designed
according to bidimensional imaging.
Internal carotid artery stenosis
3D imaging of carotid stenosis have been performed with
different techniques: (1) by the 3D reconstruction of the
internal carotid artery plaque structure from either the US
B-Mode and/or from the vessel wall parenchymal (CT/MRI)
imaging; (2) by the 3D reconstruction of the inner resid-
ual lumen, visualized with the Power Doppler or with other
imaging techniques. These two methods may have their own
disadvantages, fundamentally represented by the possibility
of under interpretation of the stenosis in case 2, because the
vessel considered as normal reference is actually only
supposed-to-be-so, not being the vessel wall directly visu-
alized. In Fig. 3 (Clip 3), the 3D reconstruction of a cases
of internal carotid artery stenosis is presented. Note as the
visualization of the missing part of the vessel lumen in 3D
US, reconstructed on the basis of the residual ow. Increased
blood ow velocities may induce an underestimation of the
stenosis in the 3D ultrasound reconstruction, because the
image is computed on the base of the ow signal increased
in this case from the inward ow. Identication of the
degree of carotid stenosis has represented a cornerstone
for the comprehension of stroke pathophysiology in stroke
history [17,18]. Nonetheless, it has to be kept in mind that
the evaluation of the degree of stenosis must always include
the study of the vessel wall and cannot be excluded, also for
its importance in analyzing plaque morphology, to identify
the unstable plaque [19].
Diagnostic pitfalls
In this study, only the 3D reconstruction of the resid-
ual lumen detected with Power mode was applied. This
method, even though images presented may seem impres-
sive, have to be considered with caution, similarly to all the
techniques that reconstruct imaging only from the inward
ow. This is particularly true in cases of internal carotid
stenosis, because if the plaque is not considered, degree
quantication is based on the comparison of what we only
suppose to be normal, and hence it may be underestimated.
E. Vicenzini et al.
Figure 4 US 3D reconstruction of moderate internal carotid
stenosis (green dotted lines). Green arrow shows the typical
artifact in 3D US reconstruction in case of low diastolic ow
due to high-resistive pattern in the external carotid artery. The
absence of signal may be erroneously misinterpreted as a vessel
occlusion.
Moreover, in these cases of the 3D US reconstruction, the
blood ow pulsating at each cardiac cycle or the acous-
tic shadow of calcic plaques may create further artifacts:
even if the persistence color setting is set to maximal values,
blood ow slowing or stopping during diastole especially
in cases of very high resistive patterns as in the external
carotid artery induce the reduction or absence of signal,
an artifact difcult to be eliminated even performing the
scan as slow as possible (Fig. 4).
Conclusions
Threedimensional ultrasound is a feasible technique when
performed by experienced examiners. It can help in the
general carotid axis imaging, better presenting the vessels
course and the caliber variations at a glance. Three-
dimensional US reconstructions from the inward ow can
also provide imaging of stenosis, but its quantication must
always take into account the assessment of plaque mor-
phology and vessels wall, by the exact knowledge of the
bidimensional images and of hemodynamic patterns.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at doi:10.1016/j.permed.
2012.03.005.
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