1108510

case-report2022
JVUXXX10.1177/15443167221108510Journal for Vascular UltrasoundBacha et al

Case Report
Journal for Vascular Ultrasound

Doppler Study of the Left Common Carotid

2022, Vol. 46(3) 129­–133
© 2022, Society for Vascular Ultrasound
Article reuse guidelines:
Artery With Preocclusive Stenosis sagepub.com/journals-permissions
DOI: 10.1177/15443167221108510
https://doi.org/10.1177/15443167221108510
journals.sagepub.com/home/jvu

Raham Bacha, PhD1,2,3, Syed Amir Gilani, MBBS, DMRD, MPH, PhD1,3,
and Iqra Manzoor, MPhil1,3

Abstract
Preocclusive stenosis of the common carotid artery is a rare and potentially life-threatening entity, and the early recognition of
associated internal and external carotid artery patency is important for the management plan. The patient in this case report
was sent for a thyroid ultrasound for complaints of neck pain, voice change, and dysphagia, and a preocclusive stenosis of the left
common carotid artery was found. Multiple collateral pathways had developed to supply blood flow to the left internal carotid
artery, and there was retrograde flow in the external carotid artery and antegrade flow in the internal carotid artery. Collaterals
from the left thyrocervical trunk were supplying the superior thyroid artery which supplied the external carotid artery and
finally the internal carotid artery through the carotid bulb. Doppler ultrasound is valuable in the identification of preocclusive
common carotid artery stenosis and mapping of collateral pathways.

Keywords
preocclusive stenosis, hemodynamically significant stenosis, collateral pathway, carotid artery, vertebral artery

Introduction left side of the thyroid gland. A thyroid sonographic examina-

Preocclusive stenosis of the common carotid artery (CCA) is a
rare clinical condition with a prevalence of 4 out of 1000.1 In
comparison to the internal carotid artery (ICA), there is very
little information published regarding CCA preocclusive steno-
sis.2 Most commonly, CCA occlusion is associated with occlu-
sion of the internal and external carotid arteries; however, in a
few cases, collateral vessels compensate to maintain blood
flow in the ICA through extracranial branches and retrograde
flow in the ipsilateral external carotid artery (ECA).3,4 In some
cases, the facial structures can be supplied by retrograde flow
in the ICA.5,6 The recognition of patency in the internal and
external carotid arteries is important for the patient manage-
ment plan.7 Carotid artery stenosis or occlusion can lead to
stroke or transient ischemic attack.8 Symptoms include motor
or sensory deficits as well as amaurosis fugax.9 Preocclusive
stenosis is described with a variety of names in the literature,
and this sometimes leads to confusion among readers and
researchers.10–14 Doppler ultrasound is the modality of choice
for the evaluation of preocclusive stenosis of the CCA.15,16
Case Presentation
A 33-year-old woman was referred to Gilani ultrasound center
in Lahore for a thyroid gland scan. The patient visited her phy-
sician for complaints of neck pain, difficulty in swallowing,
and voice change. She also had noticed a palpable mass in the
tion was performed following the American Institute of
Ultrasound in Medicine (AIUM) thyroid ultrasound protocol,
which is routinely used in this department.17,18 Color, power,
and spectral Doppler were applied for the evaluation of the
CCA, ICA, ECA, and vertebral artery.
The patient had no history of hypertension, diabetes, or any
other chronic illness. There were no signs and symptoms such
as fever, weight loss, headache, transient vision loss, transient
ischemic attacks, stroke, fatigue, dyspnea, and malaise, and she
had no history of any kind of exposure to chemicals or unfavor-
able environmental conditions. She was married for 11 years
and had 4 healthy children. She was a housewife having no
history of smoking, drinking, or any drug use. She had no
known heart disease, and her last pregnancy was 2 years prior.
Imaging Data
Ultrasound imaging of the patient was started with the thyroid
protocol. On sonographic examination, both lobes of the thyroid
1
The University of Lahore, Pakistan
2
3
Gilani Ultrasound Center, Lahore, Pakistan
Afro-Asian Institute, Lahore, Pakistan
Corresponding Author:
Raham Bacha, Associate Professor, Gilani Ultrasound Center, Lower Mall,
Lahore, 54000, Pakistan.
Email: dr.rahambacha@gmail.com
130 Journal for Vascular Ultrasound 46(3)

Figure 1.  B-mode (right) and color Doppler (left) images of the left lobe of the thyroid. Multiple small hypoechoic nodules are present
in the left lobe of the thyroid gland. Low-level echoes are seen in the left common carotid artery (Lt. CCA); however, no blood flow is
detected on color Doppler.

Figure 2.  A central faint streak of flow is observed in the left

common carotid artery (LT CCA), with the use of highly sensitive
power Doppler to detect trickle flow.
gland were normal on gray-scale imaging with a few hypoechoic
nodules noted. However, incidentally, blood flow was not
detected on color Doppler in the left CCA, while echogenic
material was observed in the vessel lumen (Figure 1). On power
Doppler examination of the left CCA, a central narrow and faint
streak of blood flow was seen, as shown in Figure 2. In most
cases of CCA narrowing, the velocity of blood flow would be
increased, but in this case, the velocity was extremely low, with
the peak systolic velocity (PSV) measured at 15.5 cm/s, as
shown in Figure 3. The stenosed area of the left CCA was mea-
sured in a short-axis view with the help of power Doppler. The
total area of the left CCA was 10.9 mm2 and the area of the
residual lumen was 0.7 mm2, resulting in an area stenosis of
93.6% (Figure 4). Antegrade, low velocity blood flow with a
PSV of 19.6 cm/s and a long systole and short diastole were
observed in the left ICA, as shown in Figure 5. Low resistive,
Figure 3.  Spectral Doppler waveform shows flow in the left
common carotid artery (LT CCA) with a low peak systolic velocity
of 15.5 cm/s.
retrograde flow with a PSV of 23.8 cm/s was observed in the left
ECA (Figure 6). Low resistive and relatively high velocity
blood flow was seen in the left vertebral artery (Figure 7).
Multiple prominent and dilated collateral vessels were
visualized in the thyroid gland with aliasing on color Doppler
(Figure 8). Collaterals from the left thyrocervical trunk were
supplying the superior thyroid artery with flow into the ECA
and finally into the CCA. Low resistive collateral flow with a
highest PSV of 22.2 cm/s was noted on spectral Doppler
forming a collateral pathway from the thyrocervical trunk to
the superior thyroid artery which in turn supplied the left
ECA. The right ECA was also supplying the superior thyroid
artery, which was supplying the left ECA. Documentation of
this left CCA preocclusive stenosis is captured in the video
Bacha et al 131
Figure 4.  Power Doppler (right) and B-mode (left) images of a
transverse or short-axis view of the left common carotid artery (LT
CCA). There is echogenic material in the arterial lumen with a small
flow channel. Percent area stenosis was measured based on the
power Doppler image. The total area of the LT CCA is 10.9 mm2,
while the residual lumen is 0.7 mm2, resulting in an area stenosis of
93.6%.
Figure 5.  Spectral Doppler waveform shows mostly antegrade
flow in the left internal carotid artery (LT ICA) with long systole
and short diastole due to inflow from collateral vessels. Flow below
the baseline in the spectral display represents flow toward the
transducer which is from left to right (caudal to cephalad).
included as supplemental material in the online version of this
case report.
Discussion
Preocclusive or near-occlusive stenosis in the common carotid
arteries is a rare clinicopathological entity.19 Usually, blood
flow velocity increases in a stenosis, but in the case of a steno-
sis greater than 90%, the velocity of blood flow decreases, and
this condition is called near-occlusive or preocclusive steno-
sis.20 This case report describes a 33-year-old female patient
Figure 6.  Spectral Doppler waveform showing retrograde flow in
the left external carotid artery (LT ECA). Flow above the baseline in
the spectral display represents flow toward the transducer which is
from left to right (cephalad to caudal).
Figure 7.  Spectral Doppler waveform showing low resistive
antegrade flow in the ipsilateral left vertebral artery (LT VA).
who developed a high-grade stenosis in the left CCA. In a pre-
vious study, the prevalence of carotid stenosis was calculated
as almost 7%, and the mean age in which carotid artery stenosis
developed was 70 years.21 In another cohort study, individuals
were followed for 5 years and re-examined at the age of 70
years. Among all the participants, 1.0% developed moderate
stenosis and 0.2% severe stenosis. Among all those with plaque,
3.6% developed moderate stenosis and 1.1% severe stenosis,
and among them, 0.6% had symptoms. Among all the males
with 50% to 79% stenosis, 12.9% had progressed to severe ste-
nosis; however, only 6.5% were symptomatic.22
Unlike most arterial stenoses, wherein flow velocity
increases with a decrease in the size of the patent lumen, in this
case, due to the very high-grade stenosis, the blood flow veloc-
ity was actually decreased. There are several different pub-
lished criteria for classifying carotid stenosis based on flow
velocities, and the Society of Radiologists in Ultrasound (SRU)
132 Journal for Vascular Ultrasound 46(3)
Figure 8.  Color Doppler image showing prominent dilated and
tortuous vessels in the thyroid gland which represent a collateral
pathway from the right external carotid artery to the left external
carotid artery.
consensus statement is one of the more widely accepted among
them.23 According to the SRU criteria, ICA stenosis of more
than 70% is considered hemodynamically significant, with the
highest PSV greater than 230 cm/s, end-diastolic velocity
greater than 100 cm/s, and an ICA to CCA velocity ratio greater
than 4.0.24 With a stenosis of 50% to 69%, the highest PSV in
the ICA is greater than 125 cm/s but less than 230 cm/s.
Increased velocities in the stenosis indicate narrowing, but the
appearance of collateral flow and decreased poststenotic flow
velocity indicate a more than 70% stenosis.25
The patient in this case report had no history of hyperten-
sion, diabetes, or dyslipidemia or any other chronic disease. In
this context, a study was conducted by the American Heart
Association, and it was reported that critical carotid artery ste-
nosis is more often present in patients with coronary artery dis-
ease, while the association of risk factors has been demonstrated
for diabetes, hypertension, and dyslipidemia.26 While research-
ing the risk factors for carotid artery stenosis, a study conducted
by Evans27 concluded that advanced age, tobacco smoking,
hyperlipidemia, hypertension, diabetes, and physical inactivity
are also factors contributing to the development of carotid ste-
nosis, and women are relatively more at risk to develop carotid
stenosis as compared to males.
This patient was found to have a CCA stenosis of more than
90%, and therefore, the blood flow velocity was decreased
beyond the stenosis. If the preocclusive stenosis is limited to
the left CCA, then the blood flow velocity may increase in the
right CCA as well as the vertebral arteries to provide collateral
flow. The inferior thyroid artery and its branches can supply
blood to the superior thyroid artery, and in turn that supplies
blood to the ECA. In the ECA, blood flows retrograde to sup-
ply the ICA (see video). Wang et al28 studied the collateral
pathways in 16 patients and found blood flow supplied to the
left ICA through retrograde flow in the ECA into the carotid
bulb. In some individuals, the left thyrocervical trunk supplied
flow to the ascending cervical artery which in turn supplied the
occipital artery to the ECA and then to the ICA. For the patient
in this case report, the right ECA was also the source of
collateral flow to the superior thyroid artery and the left ECA
and finally the left ICA.
Conclusions
Doppler ultrasound is valuable in the mapping of preocclusive
stenosis of the CCA. Beyond the region of such a high-grade
stenosis, the PSV decreases instead of increasing. Multiple col-
lateral pathways can develop to compensate for the drop in
velocity due to the preocclusive stenosis.
Acknowledgments
I would like to thank the staff members of Gilani ultrasound Center—
Sheharyaar, Ayesha, Ayesha, and Kiran—for their continuous support
and also want to say thanks to my family because without their prayers
and continuous support nothing will be possible.
Author Contributions
RB (scanned the patient, article preparation); IM (corresponding author,
article preparation, proofreading and compilation); SAG (reviewer,
supervisor). All authors read and approved the final manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
Ethics Approval and Consent to Participate
The ethical approval was taken on November 13, 2020, from the insti-
tutional review board (IRB) of the University of Lahore.
Consent for Publication
Written informed consent was obtained from the patient for publica-
tion of this case report and accompanying images.
ORCID iD
Iqra Manzoor https://orcid.org/0000-0002-3633-0349
Supplemental Material
Supplemental material for this article is available online.
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