Exclusion of echo-lucent plaque using superb micro-vascular imaging: A case report
Shigeomi Yokoya1, Akinori Kurimoto2
1Department of Neurosurgery, Saiseikai Shiga Hospital, Imperial Gift Foundation Inc., Ritto, Shiga, Japan.
Insights
Superb micro-vascular imaging (SMI) can detect extremely low blood flow velocity in the carotid bulb, aiding in the differentiation of echo-lucent plaques (ELPs) from actual blood flow when color Doppler imaging (CDI) is inconclusive. This improves diagnostic accuracy for carotid artery disease.
Area of Science:
- Vascular imaging techniques
- Carotid artery hemodynamics
- Cerebrovascular disease diagnostics
Background:
- Carotid bulb (CB) morphology can reduce blood flow velocity near the wall, promoting plaque formation.
- Echo-lucent plaques (ELPs) in the CB are a risk factor for cerebral embolism.
- Distinguishing ELPs from slow blood flow using B-mode and color Doppler imaging (CDI) in carotid ultrasonography (CU) can be challenging.
Observation:
- A case presented with a suspected ELP or thrombus in the CB due to a flow void detected by CU with CDI.
- The patient had risk factors for atherosclerosis but no neurological symptoms or signs of cerebral embolization.
- Superb micro-vascular imaging (SMI) was employed for further assessment of the carotid bulb.
Findings:
- SMI successfully visualized extremely low-velocity blood flow near the carotid bulb wall.
- This finding allowed for the exclusion of an ELP that was indistinguishable by CDI.
- The case highlights SMI's capability in detecting subtle blood flow dynamics.
Implications:
- SMI can be a valuable tool when CDI is insufficient to differentiate ELPs from slow flow in the carotid bulb.
- This imaging modality may help avoid more invasive diagnostic procedures.
- Improved characterization of carotid bulb lesions can enhance patient management and reduce risks of cerebral embolism.
Background:
In the carotid bulb (CB), the vascular morphology can cause a decrease in blood flow velocity near the vessel wall. In addition, the CB is a common site for plaque formation. Particularly, echo-lucent plaques (ELPs) are known to pose a risk for cerebral embolism, requiring careful attention. In carotid ultrasonography (CU), ELPs may be difficult to distinguish from blood flow within the vessel using only B-mode imaging; thus, the use of color Doppler imaging (CDI) is recommended. However, when blood flow is extremely slow, even CDI may fail to differentiate between ELPs and the flow. We encountered a case where superb micro-vascular imaging (SMI) successfully detected extremely low-velocity blood flow, thereby excluding the presence of an ELP that CDI could not discern.
Case Description:
A 64-year-old male with a history of smoking, hyperlipidemia, and percutaneous coronary intervention for myocardial infarction presented for an atherosclerosis screening. CU with CDI indicated a lesion showing a flow void near the wall of the CB, raising suspicions of significant blood flow stasis or the presence of an ELP or thrombus. He had no neurological findings or carotid bruits. A head magnetic resonance imaging revealed no findings suggestive of cerebral embolization. Using SMI during additional CU, we detected extremely low-velocity blood flow near the wall of the CB, allowing us to exclude an ELP.
Conclusion:
When a flow void is observed with CDI in CU, and it is difficult to differentiate between an ELP and extremely low-velocity blood flow, the application of SMI can sometimes detect the extremely low-velocity blood flow. This approach may help avoid invasive examinations such as CU with contrast agents or cerebral angiography.
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