Recommendations for multimodal noninvasive and invasive screening for detection of extracranial venous abnormalities indicative of chronic cerebrospinal venous insufficiency: a position statement of the International Society for Neurovascular Disease (original) (raw)
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BMC Neurology, 2013
Background: There is no established noninvasive or invasive diagnostic imaging modality at present that can serve as a 'gold standard' or "benchmark" for the detection of the venous anomalies, indicative of chronic cerebrospinal venous insufficiency (CCSVI). We investigated the sensitivity and specificity of 2 invasive vs. 2 noninvasive imaging techniques for the detection of extracranial venous anomalies in the internal jugular veins (IJVs) and azygos vein/vertebral veins (VVs) in patients with multiple sclerosis (MS). Methods: The data for this multimodal imaging comparison pilot study was collected in phase 2 of the "Prospective Randomized Endovascular therapy in Multiple Sclerosis" (PREMiSe) study using standardized imaging techniques. Thirty MS subjects were screened initially with Doppler sonography (DS), out of which 10 did not fulfill noninvasive screening procedure requirements on DS that consisted of ≥2 venous hemodynamic extracranial criteria. Accordingly, 20 MS patients with relapsing MS were enrolled into the multimodal diagnostic imaging study. For magnetic resonance venography (MRV), IJVs abnormal findings were considered absent or pinpoint flow, whereas abnormal VVs flow was classified as absent. Abnormalities of the VVs were determined only using non-invasive testing. Catheter venography (CV) was considered abnormal when ≥50% lumen restriction was detected, while intravascular ultrasound (IVUS) was considered abnormal when ≥50% restriction of the lumen or intra-luminal defects or reduced pulsatility was found. Non-invasive and invasive imaging modality comparisons between left, right and total IJVs and between the VVs and azygos vein were performed. Because there is no reliable way of non-invasively assessing the azygos vein, the VVs abnormalities detected by the non-invasive testing were compared to the azygos abnormalities detected by the invasive testing. All image modalities were analyzed in a blinded manner by more than one viewer, upon which consensus was reached. The sensitivity and specificity were calculated using contingency tables denoting the presence or absence of vein-specific abnormality findings between all imaging modalities used individually as the benchmark.
Przegl D Flebologiczny, 2014
Catheter venography has been considered to be the "gold standard" in the evaluation of venous pathology. Chronic cerebrospinal venous insufficiency (CCSVI) has recently been described as a condition characterised by the presence of multiple stenotic lesions of the main pathways of extracranial venous drainage, especially the internal jugular veins and the azygos vein. The primary screening diagnostic method to identify the venous lesions has been Doppler sonography. Once the abnormalities are identified by the non-invasive method, patients undergo catheter venography to confirm the presence of venous lesions with the aim of performing treatment, which has mainly been balloon angioplasty. Since the inception of CCSVI, several venographic protocols to evaluate the internal jugular and azygos veins have been described, but none of them have been scientifically validated. The purpose of this review is to analyse the most recent catheter venography protocols reported for the diagnosis and management of CCSVI. The materials and methods sections of the most recently published series describing catheter venography for the evaluation and management for CCSVI were reviewed. The technical details, including venous access selection site, catheter selection, ideal catheter position, contrast injection techniques, and interpretation of venographic findings, were reviewed. Comments on each of the technical factors are presented. Final comments with proposed techniques are presented.
BMC Medicine, 2013
The extra-cranial venous system is complex and not well studied in comparison to the peripheral venous system. A newly proposed vascular condition, named chronic cerebrospinal venous insufficiency (CCSVI), described initially in patients with multiple sclerosis (MS) has triggered intense interest in better understanding of the role of extracranial venous anomalies and developmental variants. So far, there is no established diagnostic imaging modality, non-invasive or invasive, that can serve as the "gold standard" for detection of these venous anomalies. However, consensus guidelines and standardized imaging protocols are emerging. Most likely, a multimodal imaging approach will ultimately be the most comprehensive means for screening, diagnostic and monitoring purposes. Further research is needed to determine the spectrum of extra-cranial venous pathology and to compare the imaging findings with pathological examinations. The ability to define and reliably detect noninvasively these anomalies is an essential step toward establishing their incidence and prevalence. The role for these anomalies in causing significant hemodynamic consequences for the intra-cranial venous drainage in MS patients and other neurologic disorders, and in aging, remains unproven.
Chronic cerebrospinal venous insufficiency: masked multimodal imaging assessment
Multiple Sclerosis Journal, 2013
Background: Chronic cerebrospinal venous insufficiency (CCSVI) was implicated in the pathophysiology of multiple sclerosis (MS). Objective: We evaluated neurosonography (NS), magnetic resonance venography (MRV), and transluminal venography (TLV) in subsets of MS patients drawn from a single-center, prospective, case-control study of 206 MS and 70 non-MS volunteers. Methods: As previously reported, findings on high-resolution B-mode NS imaging with color and spectral Doppler of the extracranial and intracranial venous drainage consistent with CCSVI were similar among MS and non-MS volunteers (3.88% vs 7.14%; p = 0.266). Ninety-nine MS participants consented to intravascular contrast-enhanced 3D MRV to assess their major systemic and intracranial venous circulation, and 40 advanced to TLV that included pressure measurements of the superior vena cava, internal jugular, brachiocephalic, and azygous veins. Results: NS findings and MRV patterns were discrepant for 26/98 evaluable subjects, including four with abnormal findings on NS that had normal venous anatomy by MRV. In no instance were TLV pressure gradients indicative of clinically significant functional stenosis encountered. The three imaging approaches provided generally consistent data with discrepancies referable to inherent technique properties. Conclusions: Our findings lend no support for altered venous outflow dynamics as common among MS patients, nor do they likely contribute to the disease process.
Imaging of extracranial obstructive venous disease
ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, 2018
The venous system of the head and neck generally consists of dural sinuses and cerebral veins that constitute two different vascular entities. The two cervical venous entities are not self-isolated and present with compensatory capabilities through complex connections within the craniocervical junction. This article summarizes the latest knowledge on the use of noninvasive and invasive imaging modalities in the detection of extracranial obstructive venous disease, intraluminal abnormalities, and collateral venous outflow. Moreover, it outlines the particular advantages and disadvantages of the imaging modalities at hand for detection of these abnormalities and review of the possible future directions of this field.
Behavioural Neurology, 2016
Scientific debate over chronic cerebrospinal venous insufficiency (CCSVI) has drawn attention to venous system involvement in a series of pathologic brain conditions. In the last few decades, the MRI venography (MRV) field has developed a number of valuable sequences to better investigate structural anatomy, vessel patency, and flow characteristics of venous drainage in the intra- and extracranial systems. A brief two-tier protocol is proposed to encompass the study of intra- and extracranial venous drainage with and without contrast administration, respectively. Contrast-enhanced protocol is based on time-resolved contrast-enhanced MRV of the whole region plus extracranial flow quantification through 2D Cine phase contrast (PC); non-contrast-enhanced protocol includes intracranial 3D PC, extracranial 2D time of flight (TOF), and 2D Cine PC flow quantification. Total scanning time is reasonable for clinical applications: approximately seven minutes is allocated for the contrast prot...
MEM-net and EchoColorDoppler assessment of veins draining the brain
2014
Introduction: Chronic cerebrospinal venous insufficiency (CCSVI) is characterized by multiple stenosis/obstructions affecting the principal extracranial outflow pathways of the cerebrospinal venous system. Read this study protocol and sign up to receive Journal of Vascular Diagnostics here: http://www.dovepress.com/articles.php?article\_id=17549
American Journal of Roentgenology, 2013
he introduction of the concept of chronic cerebrospinal venous insufficiency is attributed to Zamboni and colleagues [1]. They proposed that chronic cerebrospinal venous insufficiency is a vascular condition that is characterized by venous obstructive lesions involving the main extracranial outflow pathways, including the internal jugular and azygos veins [1]. According to Zamboni et al., the flow abnormalities caused by these venular obstructions may play a role in the pathogenesis of multiple sclerosis (MS) by participating in the formation of the characteristic plaques seen in this disorder [1]. Zamboni and colleagues reported that endovascular management with percutaneous transluminal angioplasty (PTA) of these venous stenotic lesions had a positive
Chronic cerebrospinal venous insufficiency
Annals of Neurology, 2013
Objective: Chronic cerebrospinal venous insufficiency (CCSVI) has been implicated in the pathophysiology of multiple sclerosis (MS). We sought to determine whether neurosonography (NS) provides reliable information on cerebral venous outflow patterns specific to MS. Methods: This was a single-center, prospective case-control study of volunteer MS and non-MS participants. A neurosonologist, blind to the subjects' diagnosis, used high-resolution B-mode imaging with color and spectral Doppler to systematically investigate, capture, and record extracranial and intracranial venous drainage. These neuroimaging results were evaluated and scored by an expert blinded to subjects' information and with no interactions with the participants. Results: Altogether, 276 subjects were studied: 206 with MS and 70 non-MS. MS patients were older than non-MS subjects (48.369.9 vs 44.3611.8 years, p<0.007), with durations from first symptoms and diagnosis of 13.7610 and 9.967.8 years, and Expanded Disability Status Scale of 2.662.0. Overall, 82 subjects (29.7%) fulfilled 1 of 5 NS criteria proposed for CCSVI; 13 (4.7%) fulfilled 2 criteria required for diagnosis, and none fulfilled >2 criteria. The distribution of subjects with 0, 1, or 2 criteria did not differ significantly across all diagnostic groupings, between MS and non-MS subjects, or within MS subgroups. CCSVI was present in 7.14% of non-MS and 3.88% of MS patients (p50.266). No significant differences emerged between MS and non-MS subjects for extracranial or intracranial venous flow rates. Interpretation: NS findings described as CCSVI are much less prevalent than initially reported, and do not distinguish MS from other subjects. Our findings do not support the hypothesis that CCSVI is causally associated with MS. ANN NEUROL 2013;73:721-728 View this article online at wileyonlinelibrary.com.