Lange Review Ultrasonography Examination, 4th Edition

Answers and Explanations

At the end of each explained answer, there is a number combination in parentheses. The first number identifies the reference source; the second number or set of numbers indicates the page or pages on which the relevant information can be found.

1. (C) Stroke is ranked in the United States as the third leading cause of death annually. (1:561)

2. (D) The emphasis of stroke as a national issue is on early diagnosis and treatment to prevent long-term disability. (2:491)

3. (C) The newest technique for early determination of a stroke, a hemorrhagic or transient ischemic attack is magnetic resonance imaging diffusion imaging. (2:491)

4. (C) Any sensory or motor deficit lasting more than 24 hours. (2:491)

5. (C) Transient ischemic attack is an acute neurologic symptom that lasts less than 24 hours and completely resolves. (3:107, 108)

6. (E) Stroke in evolution is ischemic symptoms that actively worsen during a period of observation. (3:107, 108)

7. (A) Reversible ischemic neurologic deficit is a neurologic symptom that lasts longer than 24 hours and completely resolves. (3:107, 108)

8. (D) Completed stroke is a stable neurologic deficit that had sudden onset and persists longer than 3 weeks. (3:107, 108)

9. (B) Acute brain death is caused by either lack of blood supply or effect of blood outside of normal vessels. (3:119, 243)

10. (D) Atherosclerosis is the major cause of vascular disease. (3:254)

11. (D) Ataxia, also called dystaxia, is a symptom of vertebrobasilar insufficiency, not internal carotid artery symptoms. (5:173)

12. (D) Vertigo is a neurologic symptom of vertebrobasilar disease. (5:1227)

13. (C) Ocular pneumoplethysmography is used with pressure cups over the ocular globe. (Study Guide)

14. (C) Ocular pneumoplethysmography is used to detect hemodynamically significant lesions (>60%) and in the assessment of collateral flow. (Study Guide)

15. (D) All of the above. Color Doppler units provide realtime imaging, Doppler waveform analysis, and color depiction of the flow characteristics. (Study Guide)

16. (D) A 7.5 MHz linear array is the optimal transducer for high-resolution gray-scale imaging of the carotid arteries. (Study Guide)

17. (C) 45–60° angle to the artery gives the best Doppler information. (Study Guide)

18. (C) Peak systolic velocity is the most utilized of the Doppler criteria for estimation of percentage diameter reduction. (Study Guide)

19. (A) Angle correction is mandatory when using velocity to represent Doppler shift. (3:43)

20. (C) Aliasing is an artifact that occurs with pulsed Doppler in a hemodynamically significant stenosis. (3:48)

21. (C) Change in probe position, decreasing the depth, increasing the pulse repetition frequency, increasing the Doppler angle, or lowering the frequency can correct aliasing. (3:43, 44)

22. (F) Both C and D. Two advantages of power Doppler are: it is beneficial in defining occlusive vessels and it is not dependent on beam angle and free from aliasing artifact. (3:45)

23. (B) The arterial layer of muscle and elastic tissue is the media. (Study Guide)

24. (C) The outer loose filmy layer of the artery wall is the adventitia. (Study Guide)

25. (A) The elastic inner layer of the artery wall is the intima. (Study Guide)

26. (E) Variable plaque morphology is described as heterogeneous (inhomogeneous) which sonographically appears as a non-uniform echo texture (3:162–164)

27. (D) The aortic arch is the vessel from which the cerebrovascular vessels arise. (3:134)

28. (E) All of the above. The vertebral, internal thoracic, thyrocervical, costocervical, and dorsal scapular all arise from the subclavian artery. (3:134)

29. (J) Right internal carotid artery. (Study Guide)

30. (B) Right external carotid artery. (Study Guide)

31. (F) Right subclavian artery. (Study Guide)

32. (I) Brachiocephalic trunk. (Study Guide)

33. (A) Basilar artery. (Study Guide)

34. (E) Left vertebral artery. (Study Guide)

35. (G) Left common carotid artery. (Study Guide)

36. (C) Left subclavian artery. (Study Guide)

37. (H) Aortic arch. (Study Guide)

38. (C) The common carotid artery is the main branch of the carotid system. (3:133–135)

39. (B) The internal carotid artery demonstrates a rapid increase in velocity during systole with a clear window and continuous antegrade flow during diastole. (3:133–135)

40. (D) The external carotid artery has a brisk systolic upstroke, sharp peak, and abrupt downstroke because it supplies a high-resistance system. (3:133–135)

41. (C) The common carotid artery combines the pattern of the internal and the external carotid artery. (3:133–135)

42. (A) The Carotid “bulb” exhibits a complicated turbulent flow pattern. (Study Guide)

43. (B) External carotid artery. (3:134)

44. (C) Common carotid artery. (3:134)

45. (A) Internal carotid artery. (3:134)

46. (D) Digital subtraction angiography is the radiographic modality that is the method of choice for opacifying the entire cerebral arterial system. (Study Guide)

The following are the transverse scans of the extracranial carotid arteries in the proper order according to the examination protocol:

47. (E) Brachiocephalic artery and bifurcation of the subclavian and carotid arteries (3:134)

48. (C) Common carotid artery. (3:134)

49. (D) Carotid bulb. (3:134)

50. (B) Carotid bifurcation with internal and external arteries. (3:134)

51. (A) Origin of the vertebral artery. (3:134)

The following longitudinal scan of the extracranial arteries in the proper order according to examination protocol:

52. (D) Common carotid artery from clavicle to mandible. (3:133–136)

53. (B) Carotid bifurcation (carotid bulb and proximal portion of internal and external carotid arteries. (3:133–136)

54. (E) Internal carotid artery as far distal as possible. (3:133–136)

55. (C) External carotid artery as far distal as possible. (3:133–136)

56. (A) Vertebral artery from origin as far distal as possible. (3:133–136)

57. (A) External carotid artery. (3:133–136)

58. (B) Internal carotid artery. (3:133–136)

59. (C) Common carotid artery (3:133–136)

60. (D) Carotid bulb. (3:133–136)

61. (A) Laminar flow is the normal flow pattern in the carotid artery. (3:133–136)

62. (C) Ophthalmic artery is the first major branch of the internal carotid artery with clinical significance. (3:133–136)

63. (B) Cerebral hemispheres of the brain, eyes and accessory organs, forehead, and part of the nose are supplied by blood from the internal carotid artery. (3:133–136)

64. (B) Scalp, face, and most of the neck are supplied blood from the external carotid artery. (3:134)

65. (C) Temporal tapping is the maneuver to identify that the Doppler signal is coming from the external carotid artery. (3:143, 144)

66. (B) The left common carotid artery. (3:134)

67. (D) All have the above. Turbulent flow does not necessarily have to be caused by atheromatous plaque. Sudden increase in the diameter of the blood vessel can cause turbulence. This can be seen in the carotid bulb region where the boundary layer separates from the arterial wall with an inherent reversal of flow. Tortuous arteries also can cause turbulence as blood flow is forced to change direction. Carotid kinks can cause turbulence as the arterial lumen is narrowed. (3:6)

68. (B) An increased resistivity index in the common carotid artery can indicate stenotic or occlusive disease distal to the sample site. Total occlusion of the internal carotid artery can cause a decrease in diastolic flow in the common carotid artery because of increased resistance to flow. (3:174)

69. (E) Doppler shift frequencies are affected by Doppler angle, transducer frequency, and the velocity of the red blood cells. (3:43)

70. (C) Carotid bifurcation is the most common site for atherosclerotic plaque formation. (3:134)

71. (D) None of the above. The internal carotid artery does not have a branch in the cervical section. (3:134)

72. (C) 50% diameter reduction (“critical” is a >70% diameter reduction; but hemodynamically significant is >50%?) (3:172)

Identification of the plaque morphology:

73. (E) Soft. (3:157)

74. (C) Dense. (3:157)

75. (A) Calcified. (3:157)

76. (B) Ulcerated. (3:157)

77. (D) Intraplaque hemorrhage. (3:157)

78. (B) Critical stenosis. (3:157)

79. (D) Occlusion of the internal carotid artery. (3:157)

80. (E) Reversal of flow in bulb proximal to internal carotid artery occlusion. (3:180)

81. (C) Moderate stenosis by diameter reduction. (3:180)

82. (A) Mild stenosis by diameter reduction. (3:180)

83. (D) All of the above. Distal to a critical stenosis, the spectral analysis depicts peak systole velocities decrease, end-diastole velocities decrease, and turbulent flow is seen in the spectral analysis. (3:174)

84. (D) Carotid body tumors are composed of paragangli-onic tissue and are rare neoplasms. (3:139)

85. (B) Kinking of the internal carotid artery is associated with the symptom of ischemia. (3:139)

86. (A) Identifying and operating on appropriately severe common carotid bifurcation lesions is the most common treatment to risk reduction for stroke according to NASCET. (3:135)

87. (A) The superficial temporal artery. (3:136)

88. (D) The internal carotid artery. (3:136)

89. (J) The vertebral artery. (3:136)

90. (C) The subclavian artery. (3:136)

91. (B) The supraorbital artery. (3:136)

92. (E) The ophthalmic artery. (3:136)

93. (G) The external carotid artery. (3:136)

94. (H) The superior thyroid artery. (3:136)

95. (F) The common carotid artery. (3:136)

96. (I) The brachiocephalic trunk. (3:136)

97. (E) The hypophyseal is not a branch of the subclavian. (3:136)

98. (A) The extracranial posterior circulation is composed of paired vertebral arteries in the back of the neck. (3:136)

99. (E) The subclavian steal syndrome causes ataxia, limb paralysis, vertigo, and syncope as symptoms. (3:12, 113)

100. (E) The hallmark sign of the subclavian steal syndrome is the difference of blood pressure (10–20 mm Hg) between the two arms and decreased peripheral pulse in the affected upper extremity. (3:12, 113)

101. (E) The Doppler waveform characteristics of the subclavian steal syndrome include deceleration, reversed, or alternating flow in the contralateral vertebral artery and diminished waveform distal to the stenosis or occlusion. (3:12, 113)

102. (C) The normal vertebral artery spectral analysis will depict low-resistance waveform pattern similar to the internal carotid artery. (3:148, 149)

103. (B) Normally the vertebrobasilar system provides a 10–20% percentage of blood flow to the intracranial system. (3:148–149)

104. (C) The vertebral artery can be visualized by the longitudinal plane at the level of the common carotid with the transducer angled laterally until the vertebral is seen passing through the transverse processes. (3:148, 149)

105. (C) The subclavian steal syndrome is asymptomatic at rest. (3:12, 113)

106. (B) The posterior communicating artery. (3:136)

107. (D) The middle cerebral artery. (3:136)

108. (A) The anterior cerebral artery. (3:136)

109. (F) The internal carotid artery. (3:136)

110. (H) The posterior cerebral artery. (3:136)

111. (G) The vertebral artery. (3:136)

112. (C) The anterior communicating artery. (3:136)

113. (E) The basilar artery. (3:136)

114. (E) The transcranial Doppler examination requires low frequency (2 MHz) and the appropriate software for spectral analysis calculations and computations. (3:148, 149)

115. (D) The suboccipital window examines vertebral arteries and basilar artery. (3:134–137)

116. (C) The transcranial Doppler is described as a noninvasive technique to measure the velocity of blood flow in the major intracranial brain vessels by using pulsed-waved Doppler. (3:246)

117. (E) Transcranial imaging has the advantage of observation of the narrowing of the vessel lumen, visual assessment of the transcranial vessels for localization, observation of vessel tortuosity, and calculation of the vessel lumen. (3:239–241)

118. (B) The middle cerebral artery is the largest branch of the cerebral internal carotid artery. (3:133, 134)

119. (F) The middle cerebral artery supplies blood to the frontal lobe, the temporal lobe, and the parietal lobe. (3:136)

120. (E) The middle cerebral artery is divided into M1, M2, and M3 segments. (3:136)

121. (B) The posterior communicating artery anastomoses with the posterior cerebral artery. (3:136)

122. (D) The ophthalmic artery forms extensive anastomoses with the external carotid artery. (3:136)

123. (F) All of the above. The anterior cerebral artery and its branches supply the frontal and parietal lobes, the corpus callosum, the septum pellucidum, the basil ganglia, and the anterior limb of the internal capsule. (3:136)

124. (C) The vertebral arteries unite with the basilar artery. (3:136–138)

125. (C) The basilar artery supplies the various parts of the brainstem. (3:136–138)

126. (B) The basilar artery does not give rise to the posterior communicating artery. (3:136–138)

127. (D) The anastomotic arteries that are formed by the major cerebral arteries is the circle of Willis. (3:136–138)

128. (C) Right-to-left anastomoses provide redistribution of blood flow between the sides of the body and occur via anterior communicating and basilar arteries. (3:138)

129. (D) Carotid-to-vertebral anastomoses via posterior communicating arteries. (3:136)

130. (A) Subclavian-to-carotid and subclavian-to-vertebral anastomoses involve the deep cervical artery, spinal branches of the vertebral arteries, and the ascending cervical artery. (3:136)

131. (B) ICA-to-ECA ipsilateral anastomoses superorbital and supratrochlear arteries. (3:180)

132. (E) Optical anastomoses can provide collateral flow between anterior cerebral artery, middle cerebral artery, and posterior communicating artery. (4:1228)

133. (C) Pulsatility index represents the degree of peripheral resistance. (3:236)

134. (E) A pulsatility index of >1.2 may indicate an increased intracranial pressure, vasospasm, hypercapnia, and aortic insufficiency. (3:236)

135. (E) Transtemporal window allows insonation of the middle cerebral artery (M1-M2 segments), anterior cerebral artery, and posterior cerebral artery and C1 segment of the carotid siphon. (3:122, 123)

136. (D) Suboccipital window allows insonation of vertebral arteries and basilar artery. (3:151, 152)

137. (C) Submandibular window allows insonation of the ret-romandibular internal carotid artery (distal). (3:151, 152)

138. (D) Transorbital window allows insonation of ophthalmic artery and carotid siphon (C2, C3, and C4). (Study Guide)

139. (C) Mean velocity. (3:151, 152)

140. (A) Color doppler imaging. (3:151, 152)

141. (B) Spectral waveform analysis with notation of depth, speed, and direction. (3:151, 152)

142. (D) Measurements of all arteries in the circle of Willis. (3:151)

143. (D) The carotid siphon can flow in any direction. (Study Guide)

144. (A) Internal carotid artery bifurcation flow is bidirectional. (Study Guide)

145. (C) Ml segment of MCA flow is toward the probe. (Study Guide)

146. (B) Vertebral artery flow is away from the probe. (3:143–145)

147. (B) Basilar artery flow is away from the probe. (3:143–145)

148. (B) Anterior cerebral artery (ACA) flow is away from the probe. (3:143–145)

149. (C) Posterior cerebral artery (PCA), P1 segment flows toward the probe. (3:143–145)

150. (B) PCA, P2 segment flow is away from the probe. (3:143–145)

151. (C) Ophthalmic artery flow is toward the probe. (3:143–145)

152. (D) With the occlusion or a critical stenosis of the ipsilateral extracranial carotid artery, the middle cerebral artery velocity is decreased or absent, and ophthalmic artery will decrease in flow or may have reverse flow. (3:143–145)

153. (E) Subclavian steal syndrome can be detected in intracranial vessels of the intracranial vertebral arteries and basilar artery. (3:12, 113)

154. (F) Intracranial vessel stenosis will exhibit characteristics of focal increase in the mean blood flow velocity at the site of the stenosis and color-flow Doppler will show multiple color patterns. (4:1533)

155. (D) The middle cerebral artery is the most common intracranial vessel to occlude and is seen with acute stroke. (4:1522)

156. (E) All of the above. Transcranial color Doppler can be used to examine conditions of brain death, vasospasms, arteriovenous malformations, and embolus. (3:119–243)


1. AbuRahma FA, Bergam JJ. Noninvasive Vascular Diagnosis: A Practical Guide to Therapy. 2nd ed. New York: Springer-Verlag; 2006.

2. Hof PR, Mobbs CV Handbook of Neurohiology of Aging. Philadelphia, PA: Elsevier Health Sciences; 2009.

3. Zwiebel WJ, Pellerito JS. Introduction to Vascular Ultrasonography. 5th ed. Philadelphia, PA: Elsevier Saunders; 2005.

4. Brunicardi CF. Schwartz’s Principles of Surgery. 9th ed. New York: McGraw Hill; 2010.

5. Dorland’s Illustrated Medical Dictionary. 31st ed. Philadelphia, PA: Elsevier Health Sciences; 2010.