3. Instrumentation and physical principles of carotid (Duplex) ultrasound

What you need to know before you start to practice carotid ultrasound.

3.1 Which ultrasound scanner and transducer should you use?

Carotid ultrasound is performed with a linear array probe. Such probes have a large aperture and provide high spatial resolution in the near field. Handheld ultrasound systems have been found to be comparable to mid and high range ultrasound systems (for point of care purposes). In general, it is advised to use scanners with high spatial and temporal resolution since soft plaques can easily be missed if image quality is poor.

It is recommended to optimize your settings and to define presets specifically for carotid Duplex ultrasound. Aside from a good (high resolution B image) you will need color Doppler functionality and pulsed wave (spectral Doppler) to assess flow and to quantify the degree of stenosis. Many systems also offer automatic spectral Doppler tracking (automatic velocity measurements) or automated intima media thickness calculations. In addition, you will find vendor specific color and B-Mode flow options such as: power Doppler or B mode flow. Recently there has been large interest in contrast enhanced carotid (CEUS) ultrasound. This modality provides improved flow visualization, helps to differentiate true structures from artifacts, plaque delineation (ulcerations?) and to detect neovascularization of plaque. Specific settings are required for contrast-enhanced ultrasound (CEUS).



3.2 Which settings are important when scanning the carotid arteries (carotid ultrasound)?

  • Adjust the brightness and contrast of the monitor first! The setting you chose depends on the lighting of the room. The brighter the room the brighter you will also need to adjust your monitor.
  • Use a high imaging frequency. The higher the imaging frequency the better is the spatial resolution (however you will loose penetration).
  • Adjust the depth to make sure that the artery fills the screen and that structures posterior to the carotid artery can still be seen (depth setting is usually 2-3cm)
  • Adjust the focus point at the level of the arteries


Depth settings
Optimal depth and focus setting for carotid (Duplex) ultrasound/sonography at a depth of 2,5cm. Note that the common carotid artery is seen “full screen” - still the depth is set in such a way that structures approximately 1 cm posterior to the common carotid artery are still visible. The focus point is at the level of the carotid artery.
  • Adjust the gain (avoid over- or under gaining)
  • Adjust the time gain compensation
  • Image contrast: a higher contrast helps to delineate “boarders” but the higher the contrast the less tissue information you get (you have less shades of gray in the image)
  • Tissue harmonic imaging: is a technique where the harmonic properties (resonance) of tissue are used to create the image. Its main advantage is that you have fewer artifacts. This modality is the preferred mode of imaging. Don’t turn it off!
  • Compound imaging: combines images from several steering angles to one image. Using multiple images to look at a specific region reduces artifacts and noise form the image.

Note: many scanners have an image optimization button (auto optimization) that adjusts the gain and the contrast. While this button is often helpful, don’t rely to heavily on this function.

Gain setting
Examples of different gain settings during carotid Duplex ultrasound. Note that the plaque is note displayed and can easily be missed if the gain is set too low (dark image upper right).



3.3 What is the angle of insonation in carotid ultrasound?

The angle of insonation is defined as the angle with which the ultrasound beam hits the surface of a certain structure (i.e. the carotid artery wall). The more perpendicular the angle (90°) of insonation is the more ultrasound rays are reflected back to the ultrasound transducer and the better the image quality will be.

Angle of insonation
Example of how the angle of insonation affects the quality of the image. Top right the angle of insonation is about 90° carotid artery wall. Bottom right: The angle of insonation is about 15° of of 90°. The wall of the carotid artery is less well depicted.

Angle of insonation

Angle of insonation
The angle of the ultrasound beam relative to the tissue (vessel wall)
The strongest echo are produced when the angles of incidence approaches the angle of reflection
The best B Mode image is achieved if the structure is hit perpendicular (90°)
The angle of insonation plays an important role when using color Doppler



3.4 What is pulsed wave (PW) spectral Doppler in carotid (Duplex) ultrasound?

Pulsed wave Doppler

Pulsed wave Doppler
In carotid ultrasound we use mainly pulsed wave Doppler (PW-Doppler)
With PW Doppler we are able to measure blood flow velocity within a sample volume
The Doppler velocities we measure are very dependant on the angel between the blood flow direction and the transducer
The more the angle moves towards 90° the higher the measurement error will be.
Therefore we use angel correction. We tell the scanner in which angle blood is actually flowing
The principle of Doppler is used in color- and spectral Doppler
Blood flow moving towards the transducer is depicted in red (color Doppler)
Blood flow moving towards the transducer is depicted in blue (color Doppler)
Blood flow moving toward the transducer is depicted above the baseline (spectral Doppler)
Blood flow moving away from the transducer is depicted below the baseline (spectral Doppler)
The shade of color (yellow-red, light blue - dark blue) allows us to semiquantitatively assess the velocity of blood flow
Angle correction
Sample volume of the PW Doppler spectrum – angle correction. The velocity angle must be aligned to the blood flow within the carotid artery.
Typical wave form with pulsed wave spectral Doppler in the common carotid artery (systolic and diastolic flow velocities).



3.5 What is Color Doppler (Duplex)?

Color Doppler ultrasound uses the same principles as pulsed wave Doppler. Within a region of interest (ROI – Color Doppler box) the system looks at many different “sample volumes or pixel areas” and calculates the velocity and direction of flow (for each individual area). This information is then encoded in color according to a color map scheme (which can be chosen by the operator) and displayed for each imaging frame (dynamic color flow imaging). Usually flow towards the transducer is depicted in red and colors away from the transducer in blue (unless the color encoding is inverted).

Color Doppler tracing (normal carotid ultrasound scan). The common carotid artery is seen in red, the jugular vein in blue. The color depicts the direction of flow.

The color map also assigns a different shade of color to the absolute velocity of flow. Usually the lighter the color (yellow or light blue) the higher the velocity. Note that a color shift occurs if velocities surpass the aliasing velocity (also called Nyquist limit). Color Doppler allows us to directly visualize flow (visualize vessels) and helps us to see areas where the flow velocity is elevated (aliasing).

Color Doppler
Carotid Duplex ultrasound – information provided by the Color Doppler study. Note that the velocities displayed in blue exceed the aliasing velocities.



3.6 What is aliasing in ultrasound and how do we use it during carotid Duplex sonography?


Is a Doppler phenomenon where the intermittent sampling rate (PRF) is too low to record a certain velocity
This results in an inability to measure the true velocity and flow direction
It occurs in both color and PW Doppler (because both of theses techniques use „intermittent„ sampling)
In carotid Doppler this results in a sudden shift from red to blue or blue to red, we often see a mosaic of different colors
Aliasing is helpful in US because it allows us to quickly detect regions where blood flow velocity is high
High blood flow velocity can be present in stenosis or tortuous vessels
The velocity at which aliasing occurs can be set on the scanner (PRF, aliasing velocity, Nyquist limit)
The value depicted on the color bar tells us at which velocity aliasing occurs.
Color Doppler flow within the internal carotid artery and the bifurcation. The mosaic flow (circle) shows “mosaic” flow. IT depicts areas of higher velocity where aliasing occurs. Note: The aliasing velocity is 32cm/s. The velocity at the area of turbulence must be higher than this velocity



3.7 Carotid ultrasound – artifacts

Artifacts are alterations in the image, which are not true structures but produced by physical phenomena of ultrasound and its interaction with tissue. Artifacts can occur in both good and poor image quality and typically occur with implants (i.e. metallic stents) It is important to know which potential artifacts can occur to avoid misinterpretation and misdiagnosis. Here are the most common forms of artifacts:

Acoustic enhancementStructure posterior to tissues that transmits US well is enhanced Posterior enhancement behind cysts, urinary or gallbladder
Acoustic shadowingThe US waves are completely absorbed or reflected (solid structures). Structures behind such tissue is not visibleThe vessel posterior so a calcified plaque can not be visualised. Prosthetic material, bone (rib shadow)
Beam width artifactWhen the ultrasound beam is wider than the diameter of the reflector being scanned. Adjacent structure are included into the beam and displayed as false structuresWhen scanning an anechoic structures (Cystic structures) they might appear solid
Blooming artifactWhen the color Doppler signal extends beyond the true boundaries of the vessel, spreading into adjacent regions with no actual flowOver gaining of color Doppler (A structure in a vessel might be overlapped by color and thus missed (Carotid US)
Mirror Image artifactMirror image artefacts occur in the presence of strong reflectors. The wave is reflected several times and structures are displayed several timesPericardium, diaphragm, echogenic, reflection of liver lesion into the thorax 
ReverberationWhen the US beam reflects back and forth between two strong parallel reflectors. Appears similar to mirror artefactsComet tail artefact in lung ultrasound,
Near field clutterNear field clutter occurs due to high amplitude oscillations of piezoelectric crystals. It involves the near field and may hinder identification of structures that are close to the transducerEchocardiography, display of false apical structures (which are close to the transducer in an apical view).
Example of a calcified plaque in the common carotid artery. There is “shadowing” distal to the plaque.
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