The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists,

and clinical medical

physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve
radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation
oncologists, medical physicists, and persons practicing in allied professional fields.
The American College of Radiology will periodically define new practice parameters and technical standards for radiologic practice to help advance the
science of radiology and to improve the quality of service to patients throughout the United States. Existing practice parameters and technical standards will
be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.
Each practice parameter and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has
been subjected to extensive review and approval. The practice parameters and technical standards recognize that the safe and effective use of diagnostic and
therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice
parameter and technical standard by those entities not providing these services is not authorized.

Revised 2021 (Resolution 33)*

ACR–AIUM–SPR–SRU PRACTICE PARAMETER FOR THE PERFORMANCE

OF AN ULTRASOUND EXAMINATION OF THE EXTRACRANIAL
CEREBROVASCULAR SYSTEM
PREAMBLE

This document is an educational tool designed to assist practitioners in providing appropriate radiologic care for
patients. Practice Parameters and Technical Standards are not inflexible rules or requirements of practice and are
not intended, nor should they be used, to establish a legal standard of care 1. For these reasons and those set forth
below, the American College of Radiology and our collaborating medical specialty societies caution against the use
of these documents in litigation in which the clinical decisions of a practitioner are called into question.

The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the
physician or medical physicist in light of all the circumstances presented. Thus, an approach that differs from the
practice parameters, standing alone, does not necessarily imply that the approach was below the standard of care.
To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth
in the practice parameters when, in the reasonable judgment of the practitioner, such course of action is indicated
by the condition of the patient, limitations of available resources, or advances in knowledge or technology
subsequent to publication of the practice parameters. However, a practitioner who employs an approach
substantially different from these practice parameters is advised to document in the patient record information
sufficient to explain the approach taken.

The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis,
alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always
reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it
should be recognized that adherence to these practice parameters will not assure an accurate diagnosis or a
successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action
based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical
care. The sole purpose of these practice parameters is to assist practitioners in achieving this objective.

1 Iowa Medical Society and Iowa Society of Anesthesiologists v. Iowa Board of Nursing, 831 N.W.2d 826 (Iowa 2013) Iowa Supreme Court refuses to find
that the ACR Technical Standard for Management of the Use of Radiation in Fluoroscopic Procedures (Revised 2008) sets a national standard for who may
perform fluoroscopic procedures in light of the standard’s stated purpose that ACR standards are educational tools and not intended to establish a legal standard
of care. See also, Stanley v. McCarver, 63 P.3d 1076 (Ariz. App. 2003) where in a concurring opinion the Court stated that “published standards or guidelines
of specialty medical organizations are useful in determining the duty owed or the standard of care applicable in a given situation” even though ACR standards
themselves do not establish the standard of care.

PRACTICE PARAMETER 1 US Extracranial Cerebrovascular

I. INTRODUCTION

The clinical aspects contained in specific sections of this practice parameter (Introduction, Indications,
Specifications of the Examination, and Equipment Specifications) were developed collaboratively by the American
College of Radiology (ACR), the American Institute of Ultrasound in Medicine (AIUM), the Society for Pediatric
Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU). Recommendations for physician
requirements, written request for the examination, procedure documentation, and quality control vary between the
four organizations and are addressed by each separately.

Ultrasound using grayscale imaging, Doppler spectral analysis, and color Doppler imaging (CDI) is a proven
diagnostic procedure for evaluating the extracranial cerebrovascular system. Although it is not possible to detect
every abnormality, adherence to the following practice parameters will maximize the probability of detecting most
extracranial cerebrovascular abnormalities.

II. INDICATIONS

Indications for an ultrasound examination of the extracranial carotid and vertebral arteries include, but are not
limited to:

1. Evaluation of patients with hemispheric neurologic symptoms, including stroke, transient ischemic attack,
and amaurosis fugax [1-3]
2. Evaluation of patients with a cervical bruit
3. Evaluation of pulsatile neck masses
4. Preoperative evaluation of patients scheduled for major cardiovascular surgical procedures
5. Evaluation of nonhemispheric or unexplained neurologic symptoms
6. Follow-up evaluation of patients with known or documented carotid disease
7. Postoperative or postintervention evaluation of patients following cerebrovascular revascularization,
including carotid endarterectomy, stenting, or carotid to subclavian artery bypass graft
8. Intraoperative monitoring of vascular surgery
9. Evaluation for suspected subclavian steal syndrome [4]
10. Evaluation for suspected carotid artery dissection [5], arteriovenous fistula, or pseudoaneurysm
11. Evaluation of patients with carotid reconstruction after extracorporeal membrane oxygenation (ECMO)
bypass
12. Evaluation of patients with syncope, seizures, or dizziness
13. Screening high-risk patients including atherosclerosis elsewhere, history of head and neck radiation, known
fibromuscular dysplasia (FMD), Takayasu arteritis, or other vasculopathy in another circulation
14. Neck trauma
15. Hollenhorst plaque visualized on retinal examination

III. QUALIFICATIONS AND RESPONSIBILITIES OF THE PHYSICIAN

See the ACR–SPR–SRU Practice Parameter for Performing and Interpreting Diagnostic Ultrasound Examinations
[6].

IV. WRITTEN REQUEST FOR THE EXAMINATION

The written or electronic request for extracranial cerebrovascular ultrasound examination should provide sufficient
information to demonstrate the medical necessity of the examination and allow for its proper performance and
interpretation.

Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including
known diagnoses). Additional information regarding the specific reason for the examination or a provisional
diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of
the examination.

PRACTICE PARAMETER 2 US Extracranial Cerebrovascular

The request for the examination must be originated by a physician or other appropriately licensed health care
provider. The accompanying clinical information should be provided by a physician or other appropriately licensed
health care provider familiar with the patient’s clinical problem or question and consistent with the state’s scope of
practice requirements. (ACR Resolution 35 adopted in 2006 – revised in 2016, Resolution 12-b)

V. SPECIFICATIONS OF THE EXAMINATION

Extracranial cerebrovascular ultrasound evaluation consists of assessment of the accessible portions of the common
carotid, external and internal carotid, and the vertebral arteries.

A. Scanning Technique

All arteries are scanned using appropriate grayscale and Doppler techniques and proper patient positioning [2,3,7].
The common carotid and internal carotid arteries are scanned in grayscale and with color Doppler, as completely
as possible. Caudad angulation of the transducer in the supraclavicular area and cephalad angulation at the level of
the mandible may aid visualization [3,8]. The vertebral arteries can be evaluated in the mid neck between the
vertebral transverse processes, proximally in the preforaminal (extraosseous) segment, or as they originate from the
subclavian arteries. Grayscale imaging of the common carotid artery, its bifurcation, and both the internal and
external carotid arteries is performed in longitudinal and transverse planes. Gain is optimized to detect the vessel
wall, plaque, and other abnormalities.

Color Doppler is used to detect areas of narrowing and abnormal flow to select areas for spectral analysis. Color
Doppler is also helpful to detect external carotid branches to definitively identify the external carotid artery. Color
Doppler is used to clarify the cause of image/pulsed Doppler mismatches and to detect narrow flow channels at
sites of stenoses [9]. Power Doppler evaluation may be complementary to color Doppler to search for narrow
channels of residual flow in arteries in which occlusion or near occlusion is suspected.

Long-axis spectral Doppler velocity measurements with angle correction should be obtained at representative
predetermined sites in all vessels. Additionally, scanning in and through an area of stenosis or suspected stenosis
must be adequate to determine the maximal peak systolic velocity and end diastolic velocity associated with the
stenosis and to document disturbances in the waveform distal to the stenosis.

Consistent angle correction is essential for determining blood flow velocity [2]. All angle-corrected spectral Doppler
waveforms must be obtained from longitudinal images. All patients at a facility should be scanned with the same
angle-correction technique (either parallel to the vessel wall or in line with the color flow lumen) to ensure
consistency on serial examinations and among patients. The angle of insonation should be between 45 and 60
degrees whenever possible. The potential velocity error related to incorrect angle assignment increases with
increasing Doppler angle, especially at angles above 60 degrees [3]. Angles exceeding 60 degrees should be avoided
whenever possible. Techniques to obtain an appropriate angle (eg, heel and toe angulation of the transducer) may
be necessary. Deviations from protocol may be unavoidable (eg, it may not be possible to obtain an appropriate
angle with a very tortuous vessel) but should be minimized and documented on the technologist worksheet and final
report.

Spectral Doppler gain should be appropriate for the vessel scanned. Either excessive or inadequate gain may lead
to errors.

The Doppler scale should be set to maximize the size of the waveforms without aliasing to improve accuracy and
reproducibility of measurement.

Images must be obtained with appropriate color Doppler technique to demonstrate filling of the normal lumen
and/or flow disturbances associated with stenoses. The color Doppler scale should be adjusted to avoid aliasing at
typical carotid velocities, and the gain should be set to minimize artifacts.

PRACTICE PARAMETER 3 US Extracranial Cerebrovascular

B. Recording

1. Grayscale: For each normal side evaluated, representative grayscale images must be obtained at the
following levels:
a. Long axis of common carotid artery
b. Long axis at carotid artery bifurcation
c. Long axis of internal carotid artery to include its origin
d. Short axis of proximal internal carotid artery

If abnormalities are found, additional images must be acquired:

a. If atherosclerotic plaques is present, location, extent, and characteristics should be documented with
grayscale imaging in both longitudinal and transverse planes.
b. Other vascular or significant perivascular abnormalities should be documented.

2. Color Doppler: For each normal side evaluated, color Doppler images (using color alone or as part of the
spectral Doppler image) must be obtained at each of the following levels:
a. Long axis of distal common carotid artery
b. Long axis of proximal and mid internal carotid artery
c. Long axis of external carotid artery (with identification of a branch if possible)
d. Long axis of vertebral artery

If abnormalities are found, additional images of the abnormality must be acquired.

a. If atherosclerotic plaque is present, the extent and effect on the lumen should be determined and
documented with a color flow Doppler image
b. In cases of occlusion, a color and/or power Doppler image of the occluded vessel must be acquired
c. Other vascular or significant perivascular abnormalities should be documented

3. Spectral Doppler: For each normal side evaluated, spectral Doppler waveforms and maximal peak systolic
velocities and end diastolic velocities must be recorded at each of the following levels:
a. Proximal common carotid artery
b. Mid to distal common carotid artery (generally 2-3 cm proximal to the bifurcation where the walls are
parallel to one another, namely, proximal to the bulb)
c. Proximal internal carotid artery
d. Mid to distal cervical internal carotid artery
e. Proximal external carotid artery
f. Vertebral artery (in the mid neck or at/near the origin)

If a significant stenosis is found or suspected, additional images must be recorded and the location of the stenosis
determined:
a. At the site of maximum velocity due to the stenosis
b. Distal to the site of maximal velocity to document the presence or absence of poststenotic turbulent
flow

Velocity ratios and diastolic velocities may also be calculated as warranted depending on the laboratory
interpretation criteria.

The peak systolic velocity, end diastolic velocity, waveform shape, and flow direction in each of the vertebral
arteries should be recorded.

The duplex ultrasound examination after carotid angioplasty and/or stenting requires additional images. In these
patients, grayscale, spectral, and color Doppler should be used to evaluate the lumen of the stented vessel, the stent
deployment and apposition to the artery wall at the most proximal and distal extent of the stent/s, flow within the
stents, and flow proximal and distal to the stent(s). The maximal in-stent peak systolic velocity and the waveforms
distal to this site should be documented.

PRACTICE PARAMETER 4 US Extracranial Cerebrovascular

C. Interpretation

The interpretation of cerebrovascular ultrasound requires careful attention to protocol and interpretation criteria.

1. Each laboratory must have interpretation criteria that are used by all members of the technical and physician
staff.
2. Diagnostic criteria must be derived from the literature or from internal validation based on correlation with
other imaging modalities or correlation with surgery or pathology [2,3,5,10-14].
3. The report must indicate internal carotid artery stenosis categories that are clinically useful and nationally
or internationally accepted and based primarily upon velocity criteria and waveform analysis [1-3,15].
4. Stenoses above 50% should be graded to within a range to provide adequate information for clinical
decision-making.
5. Numerous factors may falsely increase or decrease velocities (eg, systemic disease, cardiovascular disease,
contralateral severe disease or occlusion, near occlusive stenoses) [7,16-18]. Simple velocity criteria may
not be valid for children or younger adults, and other criteria, such as ratios, may be helpful in these
circumstances.
6. The report should describe abnormal waveforms, if present [4,19,20].
7. The report must indicate vertebral artery flow direction.
8. The report may characterize plaques, depending on the laboratory interpretation criteria [21-25].
9. The report should describe significant nonvascular abnormalities.
10. The criteria for common carotid and vertebral artery stenosis differ from internal carotid artery criteria
[26,27].
11. A velocity threshold that indicates an external carotid stenosis is not established. A simple description
indicating a stenosis, if present, may be reported. Identification of stenosis can be based on grayscale and/or
color flow narrowing, elevated velocity through the stenosis, and typical poststenotic waveforms.
12. The velocity criteria for stenosis after interventions may require different criteria than native vessels
[28,29]. Stents require different velocity criteria than native vessels [30-33].

VI. DOCUMENTATION

Reporting should be in accordance with the ACR Practice Parameter for Communication of Diagnostic Imaging
Findings [34].

Adequate documentation is essential for high-quality patient care. There should be a permanent record of the
ultrasound examination and its interpretation. Comparison with prior relevant imaging studies may prove helpful.
Images of all appropriate areas, both normal and abnormal, should be recorded. Variations from normal size should
generally be accompanied by measurements. The initials of the operator should be accessible on the images or
electronically in the electronic record (eg, PACS or radiology information system (RIS)). Images should be labeled
with the patient identification, facility identification, examination date, and image orientation. An official
interpretation (final report) of the ultrasound examination should be included in the patient’s medical record.
Retention of the ultrasound examination should be based on clinical need and relevant legal and local health care
facility requirements.

VII. EQUIPMENT SPECIFICATIONS

Equipment performance monitoring should be in accordance with the ACR-AAPM Technical Standard for
Diagnostic Medical Physics Performance Monitoring of Real Time Ultrasound Equipment [35].

The examination should be conducted with a real-time scanner with color, flow and spectral Doppler capability,
preferably using a linear transducer. The examination should use the highest clinically appropriate frequency,
realizing that there is a trade-off between resolution and beam penetration. Imaging frequencies should be 5.0 MHz
or greater. Doppler flow analysis should be conducted with a carrier frequency of 3.0 MHz or greater. Lower
frequencies are occasionally appropriate in patients with a large body habitus or densely calcified vessels.
Examination using lower-frequency transducers can also be useful when the vessels are not adequately imaged at

PRACTICE PARAMETER 5 US Extracranial Cerebrovascular

higher frequencies. CDI can be used to localize blood flow abnormalities for range gate placement for the Doppler
spectral analysis, thus facilitating the examination.

VIII. QUALITY CONTROL AND IMPROVEMENT, SAFETY, INFECTION CONTROL, AND

PATIENT EDUCATION

Policies and procedures related to quality, patient education, infection control, and safety should be developed and
implemented in accordance with the ACR Policy on Quality Control and Improvement, Safety, Infection Control,
and Patient Education appearing under the heading ACR Position Statement on Quality Control & Improvement,
Safety, Infection Control, and Patient Education on the ACR website (https://www.acr.org/Advocacy-and-
Economics/ACR-Position-Statements/Quality-Control-and-Improvement).

ACKNOWLEDGEMENTS

This practice parameter was revised according to the process described under the heading The Process for
Developing ACR Practice Parameters and Technical Standards on the ACR website (https://www.acr.org/Clinical-
Resources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters - Ultrasound
of the Commission on Ultrasound and the Committee on Practice Parameters – Pediatric Radiology of the
Commission on Pediatric Radiology, in collaboration with the AIUM, the SPR and the SRU.

Writing Committee – members represent their societies in the initial and final revision of this practice parameter

ACR AIUM
Laurence Needleman, MD, FACR, Chair Susan Back, MD
Tara Catanzano, MD George Berdejo, BA, RVT, FSVU
Safwan Halabi, MD Harris L. Cohen, MD, FACR, FAIUM, FSRU
Stephen I. Johnson, MD
Kristin L. Rebik, DO

SPR SRU
Rachel Crum, DO Edward I. Bluth, MD, FACR
Andrew Phelps, MD
Cicero Silva, MD

Committee on Practice Parameters – Ultrasound

(ACR Committee responsible for sponsoring the draft through the process)

Sheila Sheth, MD, FACR, Chair Stephen I. Johnson, MD

Nirvikar Dahiya, MD, FAIUM, FSRU, Vice Chair Michelle L Melany, MD, FACR
Osama Ali, MD Harriet J. Paltiel, MD
Marcela Böhm-Velez, MD, FACR Rupinder Penna, MD
Baljot S. Chahal, MD, MBA, BSc Kristin L. Rebik, DO
Christopher Fung, MD Henrietta K. Rosenberg, MD, FACR
Helena Gabriel, MD Judy H. Squires, MD
Jamie Hui, MD Joel P. Thompson, MD

Committee on Practice Parameters – Pediatric Radiology

(ACR Committee responsible for sponsoring the draft through the process)

Terry L. Levin, MD, FACR, Chair Jane Sun Kim, MD

John B. Amodio, MD, FACR Jennifer A Knight, MD
Jesse Berman, MD Jessica Kurian, MD

PRACTICE PARAMETER 6 US Extracranial Cerebrovascular

 Committee on Practice Parameters – Pediatric Radiology
Tara M. Catanzano, MB, BCh Matthew P. Lungren, MD, MPH
Harris L. Cohen, MD, FACR Helen R. Nadel, MD
Kassa Darge, MD, PhD Erica Poletto, MD
Dorothy L. Gilbertson-Dahdal, MD Richard B. Towbin, MD, FACR
Lauren P. Golding, MD Andrew T. Trout, MD
Safwan S. Halabi, MD Esben S. Vogelius, MD
Jason Higgins, DO

Lauren P. Golding, MD, Chair, Commission on Ultrasound

Richard A. Barth, MD, FACR, Chair, Commission on Pediatric Radiology
David B. Larson, MD, MBA, Chair, Commission on Quality and Safety
Mary S. Newell, MD, FACR, Chair, Committee on Practice Parameters and Technical Standards

Comment Reconciliation Committee

Eve Clark, MD, Chair Safwan Halabi, MD
Traci Pritchard, MD, FACR, Co-Chair Stephen I. Johnson, MD
Susan J. Back, MD Amy Kotsenas, MD, FACR
Richard A. Barth, MD, FACR David B. Larson, MD, MBA
George Berdejo, BA, RVT, FSVU Paul A. Larson, MD, FACR
Edward I. Bluth, MD, FACR Terry L. Levin, MD, FACR
Tara Catanzano, MD Laurence Needleman, MD, FACR
Harris L. Cohen, MD, FACR, FAIUM, FSRU Mary S. Newell, MD, FACR
Rachel Crum, DO Andrew Phelps, MD
Richard Duszak Jr., MD, FACR Kristin L. Rebik, DO
Lauren P. Golding, MD Sheila Sheth, MD, FACR
Shiva Gupta, MD Cicero Silva, MD

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PRACTICE PARAMETER 7 US Extracranial Cerebrovascular

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34. American College of Radiology. ACR practice parameter for communication of diagnostic imaging findings.
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*Practice parameters and technical standards are published annually with an effective date of October 1 in the year
in which amended, revised or approved by the ACR Council. For practice parameters and technical standards
published before 1999, the effective date was January 1 following the year in which the practice parameter or
technical standard was amended, revised, or approved by the ACR Council.

Development Chronology for This Practice Parameter

1994 (Resolution 24)
Revised 1998 (Resolution 32)
Revised 2002 (Resolution 30)
Amended 2006 (Resolution 35)
Revised 2007 (Resolution 27)
Revised 2011 (Resolution 10)
Amended 2014 (Resolution 39)
Revised 2016 (Resolution 28)
Revised 2021 (Resolution 33)

PRACTICE PARAMETER 9 US Extracranial Cerebrovascular