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Wednesday January 26, 2011. Duplex Assessment of Carotid Body Tumor. Presented by Linda Silorey and Lonni Bhirdo. Carotid Body- Anatomy. Ovoid, red/brown to tan organ Outer adventitia layer Posterior-medial wall of bifurcation of CCA

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Duplex assessment of carotid body tumor

Duplex Assessment of Carotid Body Tumor

Presented by Linda Silorey and Lonni Bhirdo


Carotid Body- Anatomy

  • Ovoid, red/brown

    to tan organ

  • Outer adventitia layer

  • Posterior-medial wall of

    bifurcation of CCA

  • 3-5 mm in size ~ larger in people in higher altitudes

  • Receives blood supply from branches of the ECA

Linda Silorey and Lonni Bhirdo


Carotid Body- Function

  • Regulates Autonomic Nervous System

  • Chemoreceptor sensitive to

    changes of arterial O2 , CO2

    and pH changes

  • Sensitive to changes in BP,

    blood flow, & blood osmolarity (salt content)

  • Sends signals to the brain

    that result in changes in

    respiratory rate/cardiac output

  • Factors such as Increased temperature of blood, Cyanide and nicotine cause stimulation of the Carotid Body

Linda Silorey and Lonni Bhirdo


Carotid body tumor
Carotid Body Tumor

aka CBT

  • Arises from the normal tissue of the carotid body between the ECA/ICA

  • Lateral pulsatile neck mass- often presenting with a bruit or thrill

  • A rare highly vascular

    tumor - incidence of only 0.01%

  • Usually benign

  • Most often fed by ECA branch:

    Ascending Pharyngeal Artery

  • Other terms used to describe CBTs:

    Chemodectomas, endothelioma glomus caroticum, peritheliomas and paragangliomas

Linda Silorey and Lonni Bhirdo


CBT- Etiology/ Incidence

  • Over- response to homeostasis changes

  • Hypertrophy linked to

    hypoxia/ hypercapnia

  • Higher Altitudes, Smoking, COPD

  • Genetic 10 % of cases

  • 45-50 years of age

  • Female - rare in children

  • South American

  • Bilateral in 5% of cases

Linda Silorey and Lonni Bhirdo


Cbt signs symptoms
CBT- Signs & Symptoms

Other Systemic Symptoms

Suggesting More Advanced

Disease Include:

Malaise

Weight Loss

Fatigue

Tachycardia

Linda Silorey and Lonni Bhirdo


Cbt diagnostic tests
CBT-Diagnostic Tests

  • DuplexUltrasound

  • MRA

  • CTA

  • Angiography

Linda Silorey and Lonni Bhirdo


Duplex Ultrasound

  • Often the examination of choice for Dx of CBT: Readily available,

  • painless, non-invasive, relatively risk free and takes less than

  • an hour

  • Always do a complete bilateral Carotid study to identify for

    Stenosis as well as to rule out a contralateral tumor

  • Machine settings and focal zones should be optimized to visualize the superficial nature of the Carotid arteries- these settings also make it possible to visualize CBTs.

  • Three modalities are used for diagnostic information:

    B-Mode or grayscale, Color flow, Doppler Spectral analysis

Linda Silorey and Lonni Bhirdo


Duplex Ultrasound: B-Mode

B-Mode/ Grayscale Helps:

  • Identify location, internal echo pattern and shape

    of any incidental finding of a neck mass

  • Differentiate whether the mass is solid or cystic

    If mass is in fact at the bifurcation

  • Whether splaying of the ICA/ ECA is a CBT

    or instead Aneurysmal Disease

    or Carotid Artery kinking

  • CBTs are solitary masses with hypoechoic,

    homogeneous or heterogeneous echo patterns

  • Margins of CBTs are well defined and smooth

Linda Silorey and Lonni Bhirdo


Duplex Ultrasound: B-Mode

  • Provides anatomical “road map”

    of Carotid Artery

  • Image in both transverse and

    longitudinal scanning planes

  • Splaying of ICA and ECA is one of primary

    ultrasound findings in Dx of CBT

  • Measure in both Trans (AP & LAT)

    and Sagittal (long) for image length

Linda Silorey and Lonni Bhirdo


SPLAYED BIFURCATION

Normal Carotid Bifurcation (Sag)

Carotid Body Tumor

Linda Silorey and Lonni Bhirdo


Duplex Ultrasound: Color Flow

  • Second to splaying, Color Flow

    Characteristics is a very valuable

    diagnostic tool in the Dx of CBT

  • Color Flow identifies blood

    flow within a tumor- a key

    feature of CBT

ICA

  • Helps identify between nonvascular,

    hypovascular and hypervascularity of

    blood flow within a tumor

ECA

  • Allows for differentiation between

    CBT and other incidental findings

    such as lymph nodes, salivary gland

    tumors and metastatic neck masses

Linda Silorey and Lonni Bhirdo


Duplex Ultrasound: Doppler

  • To further differentiate a CBT from other tumors,

  • Doppler is used to assess the spectral waveforms

  • of the arteries within and feeding the CBT

  • Waveforms are most commonly Low-Resistant within

  • the tumor and feeding vessels

  • There is also usually increased Diastolic Flow in the ECA

  • artery branch feeding the tumor

Linda Silorey and Lonni Bhirdo


Reporting of CBT

  • CBT is only one of many types of masses that can be found when performing a Carotid Duplex examination

  • Other findings include: Enlarged Lymph Nodes

    Metastatic Lesions

    Thyroid or Parathyroid Masses

    Lipomas

    Salivary Gland Tumors

    Tumors of Nerve Sheath (Schwannoma)

    • Important to note location of mass in relation to surrounding landmarks/structures

    • Measurements listed in three planes: AP, Lat and Sag

    • Description of mass: round, oval, lobular

    • Margin or Boarders: well defined, poorly visualized, diffused, regular, irregular

    • Echo Patterns (compared to surrounding tissue): Hypo/Hyperechoic

    • Color Flow Patterns: Flow vs No Flow visualized

Linda Silorey and Lonni Bhirdo









Treatment
Treatment

  • The tumor is classified via the Shamblin

    classification- which is based on the tumor’s

    involvement of the ICA

  • Usually slow growing, surgical resection is the

    most common treatment due to invasive nature

    of CBTs. They are often found wrapped around

    the ICA and ECA, can erode into the base of skull

    and can entrap regional cranial nerves

  • Feeding vessels are often embolized 1-2 days prior to

    resection to reduce tumor size, ease the resection

    and reduce intraoperative blood loss

  • The ECA is sometimes sacrificed to control bleeding

    and improve access to the ICA. Immediate repair or

    replacement of the CCA and or ICA may be needed

Linda Silorey and Lonni Bhirdo


CBT- Prognosis

  • Post surgery stroke

    and cranialnerveinjury

    risk was 35%

  • 3-9 % mortality rate

  • Incompleteexcision has

    overallrecurrence rate of

    10-15%

  • Significant increase in mortality rate with CarotidArteryligation

Linda Silorey and Lonni Bhirdo


Special Thanks

to

Macomb Surgical Associates!!!

Linda Silorey and Lonni Bhirdo


References

Linda Silorey and Lonni Bhirdo


References- cont.

Picture Sites

http://medical-dictionary.thefreedictionary.com/carotid+body

http://www.cvrx.com/patients/index.php?id=41

http://www.cvrx.com/patients/index.php?id=41

http://www.radrounds.com/photo/carotid-body-tumor-64row-mdct?context=user

http://www.imagingeconomics.com/issues/articles/MI_2006-01_10.asp

http://wjso.com/content/3/1/10

http://www.daviddarling.info/encyclopedia/C/carotid_ultrasound.html

http://oto.sagepub.com/content/118/1/82.abstract

http://www.vascularweb.org/APDVS/Pages/CerebrovascularModule.aspx

http://www.centrus.com.br/DiplomaFMF/SeriesFMF/18-23-weeks/chapter- 13/sga_01.html

http://www.healthcaremagic.com/healthpage/branchial-cyst

Linda Silorey and Lonni Bhirdo


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