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Observations of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis patients using a multimodality imaging protocol
Richard F. Neville, MD1, Carlo Tornatore, MD2, James Laredo, PhD3, Byung-Boong Lee, MD, PhD3, Anton N. Sidawy, MD3.
1Surgery, Division of Vascular Surgery Georgetown University, Washington, DC, USA, 2Division of Neurology Georgetown University, Washington, DC, USA, 3Division of Vascular Surgery Georgetown University, Washington, DC, USA.
Objective: Chronic cerebrospinal venous insufficiency (CCSVI) has been implicated in the etiology of multiple sclerosis (MS) with truncular venous malformations leading to stenosis of the jugular (IJV) and azygous veins resulting in insufficient drainage of the cerebrospinal venous circulation. Consistent with this theory is an increased mean transit time in MRI perfusion studies and histology showing hemosiderin deposits and pericapillary fibrin cuffs. This study prospectively evaluated patients with MS for the presence of CCSVI using Duplex ultrasound (US), venography, and intravascular ultrasound (IVUS).
Methods: This prospective analysis was performed under IRB approval (IRB# 2010-186, August 2010). 100 consecutive patients with MS were screened by US using parameters of flow direction (reflux), B mode abnormalities (stenosis, webs, septum), obstructed flow, and decreased venous area below 0.4 cm2 (no widening in the supine position). CCSVI was positive if two or more of these criteria were found with those patients undergoing venography with IVUS. Venous angioplasty was performed in patients with IJV or azygous stenosis by venography confirmed by IVUS. Balloon size was guided by IVUS measurements using low pressure balloons and prolonged inflation times. Post treatment venography and IVUS were performed in all treated patients. No stents were deployed.
Results: US findings were positive for CCSVI in 57% of patients screened. The most common finding was abnormal flow direction with unilateral reflux in 52% and bilateral reflux in 43%; right IJV in 57% (reflux time 0.55-1.70 seconds) and left IJV in 62% (reflux time 0.68-2.25 seconds). Venograms were performed in 48 patients with abnormalities in 35 (73%); right IJV stenosis (29%), left IJV stenosis (33%), and azygous stenosis (10%). IVUS imaging confirmed sclerotic, hyperplastic areas of stenosis, but also identified venographic “pseudostenosis” of the proximal IJV valve in various states of closure. In 32 patients (67%) angioplasty was performed; right IJV (9, 28%), left IJV (13, 41%) and the azygous vein (4, 12.5%). Venography and IVUS were performed post-angioplasty.
Conclusion: This study describes initial observations of imaging the cervical venous circulation in patients with MS. There were a substantial number of patients with venous abnormalities; however there was no comparative normal group. IVUS was critical in differentiating true abnormalities from venous valvular phenomenon which may prove essential in guiding intervention if a causal relationship is proven.
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