1
|
Cho J, Nguyen TD, Huang W, Sweeney EM, Luo X, Kovanlikaya I, Zhang S, Gillen KM, Spincemaille P, Gupta A, Gauthier SA, Wang Y. Brain oxygen extraction fraction mapping in patients with multiple sclerosis. J Cereb Blood Flow Metab 2022; 42:338-348. [PMID: 34558996 PMCID: PMC9122515 DOI: 10.1177/0271678x211048031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
We aimed to demonstrate the feasibility of whole brain oxygen extraction fraction (OEF) mapping for measuring lesion specific and regional OEF abnormalities in multiple sclerosis (MS) patients. In 22 MS patients and 11 healthy controls (HC), OEF and neural tissue susceptibility (χn) maps were computed from MRI multi-echo gradient echo data. In MS patients, 80 chronic active lesions with hyperintense rim on quantitative susceptibility mapping were identified, and the mean OEF and χn within the rim and core were compared using linear mixed-effect model analysis. The rim showed higher OEF and χn than the core: relative to their adjacent normal appearing white matter, OEF contrast = -6.6 ± 7.0% vs. -9.8 ± 7.8% (p < 0.001) and χn contrast = 33.9 ± 20.3 ppb vs. 25.7 ± 20.5 ppb (p = 0.017). Between MS and HC, OEF and χn were compared using a linear regression model in subject-based regions of interest. In the whole brain, compared to HC, MS had lower OEF, 30.4 ± 3.3% vs. 21.4 ± 4.4% (p < 0.001), and higher χn, -23.7 ± 7.0 ppb vs. -11.3 ± 7.7 ppb (p = 0.018). Our feasibility study suggests that OEF may serve as a useful quantitative marker of tissue oxygen utilization in MS.
Collapse
Affiliation(s)
- Junghun Cho
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Thanh D Nguyen
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Weiyuan Huang
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Elizabeth M Sweeney
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Xianfu Luo
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | | | - Shun Zhang
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Kelly M Gillen
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Susan A Gauthier
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA.,Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Yi Wang
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA.,Department of Biomedical Engineering, Cornell University, Ithaca, NY, USA
| |
Collapse
|
2
|
Zhang C, Wu B, Wang X, Chen C, Zhao R, Lu H, Zhu H, Xue B, Liang H, Sethi SK, Haacke EM, Zhu J, Peng Y, Cheng J. Vascular, flow and perfusion abnormalities in Parkinson's disease. Parkinsonism Relat Disord 2020; 73:8-13. [DOI: 10.1016/j.parkreldis.2020.02.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 12/15/2022]
|
3
|
Ding J, Guan J, Rajah G, Dornbos D, Li W, Wang Z, Ding Y, Ji X, Meng R. Clinical and neuroimaging correlates among cohorts of cerebral arteriostenosis, venostenosis and arterio-venous stenosis. Aging (Albany NY) 2019; 11:11073-11083. [PMID: 31790365 PMCID: PMC6932895 DOI: 10.18632/aging.102511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/18/2019] [Indexed: 12/15/2022]
Abstract
The purpose of this study was to discriminate the clinical and imaging correlates of cerebral arterial stenosis (CAS), venous stenosis (CVS) and arterio-venous stenosis (CAVS) in the clinical setting. Patients were classified into three groups: CAS (n = 75), CVS (n=74) and CAVS (n=67). Focal neurological deficits were the prominent presenting symptoms in CAS group, while venous turbulence related symptoms were common in both CVS and CAVS group. Risk factor analysis showed the OR (95%CI) for diabetes, male gender and age in CAS vs. CVS group were 13.67(2.71, 68.85), 6.69(2.39, 18.67) and 1.07(1.03, 1.12) respectively. Male gender, diabetes and age in CAVS vs. CAS groups were 0.27(0.11, 0.63), 0.26(0.10, 0.67) and 1.09(1.04, 1.14) respectively, while age in CAVS vs. CVS group was 1.11(1.07, 1.15). The white matter lesions (WMLs) in CAS group varied in size, with clear boundaries asymmetrically distributed in bilateral hemispheres. CVS-induced WMLs revealed a bilaterally symmetric, cloudy-like appearance. The cerebral perfusion was asymmetrically reduced in CAS but symmetrically reduced in CVS group. The clinical characteristics and neuroimaging presentations were different among patients with CAS, CVS and CAVS. We recommended for aged patients, both arterial and venous imaging should be considered in diagnosis of cerebral stenotic vascular disorders.
Collapse
Affiliation(s)
- Jiayue Ding
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jingwei Guan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Gary Rajah
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY 14203, USA
| | - David Dornbos
- Department of Neurological Surgery, Semmes-Murphey Clinic and the University of Tennessee Health Science Center, Memphis, TN 38103, USA
| | - Weili Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhongao Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Xunming Ji
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
4
|
Sethi SK, Daugherty AM, Gadda G, Utriainen DT, Jiang J, Raz N, Haacke EM. Jugular Anomalies in Multiple Sclerosis Are Associated with Increased Collateral Venous Flow. AJNR Am J Neuroradiol 2017; 38:1617-1622. [PMID: 28546249 DOI: 10.3174/ajnr.a5219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 03/13/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE To date, research on extracranial venous collaterals has been focused on structure, with relatively little attention paid to hemodynamics. We addressed this limitation by quantitatively comparing collateral flow in patients with multiple sclerosis and healthy controls by using phase-contrast MR imaging. We hypothesize that patients with MS with structurally anomalous internal jugular veins will have elevated collateral venous flow compared with healthy controls. MATERIALS AND METHODS The sample consisted of 276 patients with MS and 106 healthy controls. We used MRV to classify internal jugular veins as stenotic and nonstenotic based on an absolute cross-sectional area threshold in 276 patients with MS and 60 healthy controls; 46 healthy controls lacked this imaging. Individual and total vessel flows were quantified by using phase-contrast MR imaging on all patients. Veins were classified by extracranial drainage type: internal jugular veins (I), paraspinal (II), and superficial (III). Differences among healthy controls, patients with MS, nonstenotic patients, and stenotic subgroups in total venous flow by vessel type were evaluated in a general linear model for statistical analysis. RESULTS In the MS group, 153 patients (55%) evidenced stenosis, whereas 12 (20%) healthy controls were classified as stenotic (P < .001). Compared with healthy controls, the MS group showed lower type I flow and increased type II flow. Stenosis was associated with reduced flow in the type I vessels [F(1272) = 68; P < .001]. The stenotic MS group had increased flow in the type II vessels compared with the nonstenotic MS group [F(1272) = 67; P < .001]. CONCLUSIONS Compared with healthy controls, patients with MS exhibit reduced venous flow in the main extracerebral drainage vein (internal jugular vein). In contrast, flow in the paraspinal venous collaterals is elevated in patients with MS and exacerbated by venous stenosis. Collateral drainage may be a compensatory response to internal jugular vein flow reduction.
Collapse
Affiliation(s)
- S K Sethi
- From The MRI Institute for Biomedical Research (S.K.S., D.T.U., J.J., E.M.H.), Detroit, Michigan
| | | | - G Gadda
- Department of Physics and Earth Sciences (G.G.), University of Ferrara, Ferrara, Italy
| | - D T Utriainen
- From The MRI Institute for Biomedical Research (S.K.S., D.T.U., J.J., E.M.H.), Detroit, Michigan
| | - J Jiang
- From The MRI Institute for Biomedical Research (S.K.S., D.T.U., J.J., E.M.H.), Detroit, Michigan
| | - N Raz
- Institute of Gerontology (A.M.D., N.R.)
- Departments of Psychology (N.R.)
| | - E M Haacke
- From The MRI Institute for Biomedical Research (S.K.S., D.T.U., J.J., E.M.H.), Detroit, Michigan
- Radiology (E.M.H.), Wayne State University, Detroit, Michigan
| |
Collapse
|
5
|
Laukontaus SJ, Pekkola J, Numminen J, Kagayama T, Lepäntalo M, Färkkilä M, Atula S, Tienari P, Venermo M. Magnetic Resonance Imaging of Internal Jugular Veins in Multiple Sclerosis: Interobserver Agreement and Comparison with Doppler Ultrasound Examination. Ann Vasc Surg 2017; 42:84-92. [DOI: 10.1016/j.avsg.2016.10.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/15/2016] [Accepted: 10/09/2016] [Indexed: 10/20/2022]
|
6
|
Garcia JR, Sanyal A, Fatemifar F, Mottahedi M, Han HC. Twist buckling of veins under torsional loading. J Biomech 2017; 58:123-130. [PMID: 28526174 DOI: 10.1016/j.jbiomech.2017.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/31/2017] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
Veins are often subjected to torsion and twisted veins can hinder and disrupt normal blood flow but their mechanical behavior under torsion is poorly understood. The objective of this study was to investigate the twist deformation and buckling behavior of veins under torsion. Twist buckling tests were performed on porcine internal jugular veins (IJVs) and human great saphenous veins (GSVs) at various axial stretch ratio and lumen pressure conditions to determine their critical buckling torques and critical buckling twist angles. The mechanical behavior under torsion was characterized using a two-fiber strain energy density function and the buckling behavior was then simulated using finite element analysis. Our results demonstrated that twist buckling occurred in all veins under excessive torque characterized by a sudden kink formation. The critical buckling torque increased significantly with increasing lumen pressure for both porcine IJV and human GSV. But lumen pressure and axial stretch had little effect on the critical twist angle. The human GSVs are stiffer than the porcine IJVs. Finite element simulations captured the buckling behavior for individual veins under simultaneous extension, inflation, and torsion with strong correlation between predicted critical buckling torques and experimental data (R2=0.96). We conclude that veins can buckle under torsion loading and the lumen pressure significantly affects the critical buckling torque. These results improve our understanding of vein twist behavior and help identify key factors associated in the formation of twisted veins.
Collapse
Affiliation(s)
- Justin R Garcia
- Department of Mechanical Engineering, University of Texas at San Antonio, USA; Biomedical Engineering Program, UTSA-UTHSCSA, USA
| | - Arnav Sanyal
- Department of Mechanical Engineering, University of Texas at San Antonio, USA
| | - Fatemeh Fatemifar
- Department of Mechanical Engineering, University of Texas at San Antonio, USA
| | - Mohammad Mottahedi
- Department of Mechanical Engineering, University of Texas at San Antonio, USA
| | - Hai-Chao Han
- Department of Mechanical Engineering, University of Texas at San Antonio, USA; Biomedical Engineering Program, UTSA-UTHSCSA, USA; Institute of Mechanobiology & Medical Engineering, Shanghai Jiaotong University, China.
| |
Collapse
|
7
|
Martin N, Traboulsee AL, Machan L, Klass D, Ellchuk T, Zhao Y, Knox KB, Kopriva D, Lala S, Nickel D, Otani R, Perera WR, Rauscher A, Sadovnick AD, Szkup P, Li DK. Prevalence of Extracranial Venous Narrowing on Magnetic Resonance Venography Is Similar in People With Multiple Sclerosis, Their Siblings, and Unrelated Healthy Controls: A Blinded, Case-Control Study. Can Assoc Radiol J 2016; 68:202-209. [PMID: 27887935 DOI: 10.1016/j.carj.2016.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 01/09/2016] [Accepted: 07/06/2016] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The study sought to assess and compare the prevalence of narrowing of the major extracranial veins in subjects with multiple sclerosis and controls, and to assess the sensitivity and specificity of magnetic resonance venography (MRV) for describing extracranial venous narrowing as it applies to the chronic cerebrospinal venous insufficiency theory, using catheter venography (CV) as the gold standard. METHODS The jugular and azygos veins were assessed with time-of-flight MRV in this assessor-blinded, case-control study of subjects with multiple sclerosis, their unaffected siblings, and unrelated controls. The veins were evaluated by diameter and area, and compared with CV. Collateral vessels were also analyzed for maximal diameter, as a potential indicator of compensatory flow. RESULTS A high prevalence of extracranial venous narrowing was demonstrated in all study groups, collectively up to 84% by diameter criteria and 90% by area, with no significant difference between the groups when assessed independently (P = .34 and .63, respectively). There was high interobserver variability in the reporting of vessel narrowing (kappa = 0.32), and poor vessel per vessel correlation between narrowing on MRV and CV (kappa = 0.064). Collateral neck veins demonstrated no convincing difference in maximum size or correlation with jugular narrowing. CONCLUSION There is a high prevalence of narrowing of the major extracranial veins on MRV in all 3 study groups, with no significant difference between them. These findings do not support the chronic cerebrospinal venous insufficiency theory. Although MRV has shown a high sensitivity for identifying venous narrowing, time-of-flight imaging demonstrates poor interobserver agreement and poor specificity when compared with the gold standard CV.
Collapse
Affiliation(s)
- Nancy Martin
- Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Anthony L Traboulsee
- Department of Medicine (Neurology), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lindsay Machan
- Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Darren Klass
- Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tasha Ellchuk
- Department of Medical Imaging, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Yinshan Zhao
- Department of Medicine (Neurology), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Katherine B Knox
- Department of Physical Medicine and Rehabilitation, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - David Kopriva
- Department of Surgery, College of Medicine, University of Saskatchewan and Regina Qu'Appelle Health Region (Section of Vascular Surgery), Regina, Saskatchewan, Canada
| | - Shantilal Lala
- Department of Medical Imaging, College of Medicine, University of Saskatchewan and Regina Qu-Appelle Health Region, Regina, Saskatchewan, Canada
| | - Darren Nickel
- Department of Physical Medicine and Rehabilitation, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Robert Otani
- Department of Medical Imaging, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Warren R Perera
- Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexander Rauscher
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - A Dessa Sadovnick
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Szkup
- Department of Medical Imaging, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - David K Li
- Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
8
|
Jang J, Kim BS, Sung J, Kim BY, Choi HS, Jung SL, Ahn KJ. Subtraction MR Venography Acquired from Time-Resolved Contrast-Enhanced MR Angiography: Comparison with Phase-Contrast MR Venography and Single-Phase Contrast-Enhanced MR Venography. Korean J Radiol 2015; 16:1353-63. [PMID: 26576127 PMCID: PMC4644759 DOI: 10.3348/kjr.2015.16.6.1353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 07/21/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the image characteristics of subtraction magnetic resonance venography (SMRV) from time-resolved contrast-enhanced MR angiography (TRMRA) compared with phase-contrast MR venography (PCMRV) and single-phase contrast-enhanced MR venography (CEMRV). MATERIALS AND METHODS Twenty-one patients who underwent brain MR venography (MRV) using standard protocols (PCMRV, CEMRV, and TRMRA) were included. SMRV was made by subtracting the arterial phase data from the venous phase data in TRMRA. Co-registration and subtraction of the two volume data was done using commercially available software. Image quality and the degree of arterial contamination of the three MRVs were compared. In the three MRVs, 19 pre-defined venous structures (14 dural sinuses and 5 cerebral veins) were evaluated. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the three MRVs were also compared. RESULTS Single-phase contrast-enhanced MR venography showed better image quality (median score 4 in both reviewers) than did the other two MRVs (p < 0.001), whereas SMRV (median score 3 in both reviewers) and PCMRV (median score 3 in both reviewers) had similar image quality (p ≥ 0.951). SMRV (median score 0 in both reviewers) suppressed arterial signal better than did the other MRVs (median score 1 in CEMRV, median score 2 in PCMRV, both reviewers) (p < 0.001). The dural sinus score of SMRV (median and interquartile range [IQR] 48, 43-50 for reviewer 1, 47, 43-49 for reviewer 2) was significantly higher than for PCMRV (median and IQR 31, 25-34 for reviewer 1, 30, 23-32 for reviewer 2) (p < 0.01) and did not differ from that of CEMRV (median and IQR 50, 47-52 for reviewer 1, 49, 45-51 for reviewer 2) (p = 0.146 in reviewer 1 and 0.123 in reviewer 2). The SNR and CNR of SMRV (median and IQR 104.5, 83.1-121.2 and 104.1, 74.9-120.5, respectively) were between those of CEMRV (median and IQR 150.3, 111-182.6 and 148.4, 108-178.2) and PCMRV (median and IQR 59.4, 49.2-74.9 and 53.6, 43.8-69.2). CONCLUSION Subtraction magnetic resonance venography is a promising MRV method, with acceptable image quality and good arterial suppression.
Collapse
Affiliation(s)
- Jinhee Jang
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | - Bum-Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | - Jinkyeong Sung
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Bom-Yi Kim
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | - Hyun Seok Choi
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | - So-Lyung Jung
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | - Kook-Jin Ahn
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| |
Collapse
|
9
|
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. J Vasc Interv Radiol 2014; 25:1785-94.e17. [DOI: 10.1016/j.jvir.2014.07.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Revised: 07/07/2014] [Accepted: 07/14/2014] [Indexed: 11/19/2022] Open
|
10
|
Raz E, Pontecorvo S, Barra V, Marincola BC, Morreale M, Tinelli E, Saba L, Di Paolo PL, Aceti A, Catalano C, Francia A, Caramia F. MR venography in patients with multiple sclerosis and correlation with clinical and MRI parameters. J Neuroimaging 2014; 24:492-7. [PMID: 25340182 DOI: 10.1111/jon.12066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Multiple sclerosis (MS) has been associated with chronic cerebrospinal venous insufficiency. We aim to evaluate the correlation between extracranial veins stenosis evaluated with MR venography (MRV) and clinical/MR parameters of MS. METHODS In 29 consecutive MS patients we performed a standard brain MRI protocol, completed by the evaluation of extra-cerebral venous system using a phase-contrast and a Volumetric Interpolated Breath Hold Examination (VIBE) sequence before and after gadolinium. The T2-proton density images were used to calculate the lesion volume. The jugular veins were evaluated qualitatively (in terms of presence and severity of stenoses) and quantitatively (degree of stenosis). The phase-contrast images were analyzed to calculate the average and peak velocity in the internal jugular veins. RESULTS Postcontrast VIBE successfully showed the jugular veins in all the subjects. T2-lesion-volume was 8.2 [4.6] cm³. A stenosis of the internal jugular veins > of 50% was observed in 10/29(33%) patients. No significant correlation was observed between T2-lesion-volume and degree-of-stenosis (r = .362, P = .302). No different flow parameters were found in the subgroups of patients with and without stenosis (P = .54). CONCLUSIONS In MS the presence/severity of jugular vein stenosis identified with 3T-MRV is not related to MR-visible tissue damage. Moreover no abnormal flow parameters were found in stenosed veins.
Collapse
|
11
|
Veroux P, Giaquinta A, Perricone D, Lupo L, Gentile F, Virgilio C, Carbonaro A, De Pasquale C, Veroux M. Internal jugular veins out flow in patients with multiple sclerosis:a catheter venography study. J Vasc Interv Radiol 2014; 24:1790-7. [PMID: 24409471 DOI: 10.1016/j.jvir.2013.08.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To investigate an examiner-independent catheter venography protocol that could be used to reliably diagnose venous outflow abnormalities in patients with multiple sclerosis (MS) and chronic cerebrospinal venous insufficiency and to determine whether venous angioplasty is effective in the treatment of these abnormalities. MATERIALS AND METHODS A total of 313 patients with MS and 12 patients with end-stage renal disease underwent echo-color Doppler sonography and catheter venography of the internal jugular veins (IJVs) to evaluate contrast medium clearance time. In patients with venous outflow anomalies, balloon angioplasty of the IJVs was performed. RESULTS A contrast medium clearance time cutoff value of 4 seconds or less provided the maximal combination of sensitivity and specificity for the right IJV (sensitivity, 73.4%; specificity, 100%) and left IJV (sensitivity, 91.4%; specificity, 100%). IJVs with a clearance time between 4.1 and 6 seconds had moderate delayed flow (MDF), and IJVs with a clearance time longer than 6 seconds had severe delayed flow (SDF); 89% of patients showed MDF/SDF through at least one IJV, 79% showed MDF/SDF through both IJVs, and only 5% showed normal flow in both IJVs. Balloon angioplasty was immediately able to improve flow in at least one IJV in 69% of patients, but venous flow was normalized in both veins in only 37% of patients; SDF persisted after angioplasty in 32% of patients. CONCLUSIONS There is a high prevalence of abnormal delayed flow through IJVs in patients with MS. Venous angioplasty was effective in only a minority of patients with SDF.
Collapse
|
12
|
Harloff A. Cerebral veins-why functional MR imaging is worth the trouble. AJNR Am J Neuroradiol 2014; 35:1007-8. [PMID: 24335540 DOI: 10.3174/ajnr.a3811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- A Harloff
- Department of Neurology University Medical Center Freiburg, Germany
| |
Collapse
|
13
|
Traboulsee AL, Knox KB, Machan L, Zhao Y, Yee I, Rauscher A, Klass D, Szkup P, Otani R, Kopriva D, Lala S, Li DK, Sadovnick D. Prevalence of extracranial venous narrowing on catheter venography in people with multiple sclerosis, their siblings, and unrelated healthy controls: a blinded, case-control study. Lancet 2014; 383:138-45. [PMID: 24119384 DOI: 10.1016/s0140-6736(13)61747-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Chronic cerebrospinal venous insufficiency has been proposed as a unique combination of extracranial venous blockages and haemodynamic flow abnormalities that occurs only in patients with multiple sclerosis and not in healthy people. Initial reports indicated that all patients with multiple sclerosis had chronic cerebrospinal venous insufficiency. We aimed to establish the prevalence of venous narrowing in people with multiple sclerosis, unaffected full siblings, and unrelated healthy volunteers. METHODS We did an assessor-blinded, case-control, multicentre study of people with multiple sclerosis, unaffected siblings, and unrelated healthy volunteers. We enrolled the study participants between January, 2011 and March, 2012, and they comprised 177 adults: 79 with multiple sclerosis, 55 siblings, and 43 unrelated controls, from three centres in Canada. We assessed narrowing of the internal jugular and azygous veins with catheter venography and ultrasound criteria for chronic cerebrospinal venous insufficiency proposed by Zamboni and colleagues. Catheter venography data were available for 149 participants and ultrasound data for 171 participants. FINDINGS Catheter venography criteria for chronic cerebrospinal venous insufficiency were positive for one of 65 (2%) people with multiple sclerosis, one of 46 (2%) siblings, and one of 32 (3%) unrelated controls (p=1·0 for all comparisons). Greater than 50% narrowing of any major vein was present in 48 of 65 (74%) people with multiple sclerosis, 31 of 47 (66%) siblings (p=0·41 for comparison with patients with multiple sclerosis), and 26 of 37 (70%) unrelated controls (p=0·82). The ultrasound criteria for chronic cerebrospinal venous insufficiency were fulfilled in 35 of 79 (44%) participants with multiple sclerosis, 17 of 54 (31%) siblings (p=0·15 for comparison with patients with multiple sclerosis) and 17 of 38 (45%) unrelated controls (p=0·98). The sensitivity of the ultrasound criteria for detection of greater than 50% narrowing on catheter venography was 0·406 (95% CI 0·311-0·508), and specificity was 0·643 (0·480-0·780). INTERPRETATION This study shows that chronic cerebrospinal venous insufficiency occurs rarely in both patients with multiple sclerosis and in healthy people. Extracranial venous narrowing of greater than 50% is a frequent finding in patients with multiple sclerosis, unaffected siblings, and unrelated controls. The ultrasound criteria are neither sensitive nor specific for narrowing on catheter venography. The significance of venous narrowing to multiple sclerosis symptomatology remains unknown. FUNDING MS Society of Canada, Saskatoon City Hospital Foundation, Lotte and John Hecht Memorial Foundation, Vancouver Coastal Health Foundation, and the Wolridge Foundation.
Collapse
Affiliation(s)
| | - Katherine B Knox
- Department of Physical Medicine and Rehabilitation, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Lindsay Machan
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Yinshan Zhao
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Irene Yee
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Alexander Rauscher
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Darren Klass
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Peter Szkup
- Department of Medical Imaging, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Robert Otani
- Department of Medical Imaging, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - David Kopriva
- Department of Surgery, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Shanti Lala
- Department of Surgery, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - David K Li
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Dessa Sadovnick
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
14
|
Zivadinov R, Chung CP. Potential involvement of the extracranial venous system in central nervous system disorders and aging. BMC Med 2013; 11:260. [PMID: 24344742 PMCID: PMC3866257 DOI: 10.1186/1741-7015-11-260] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 11/22/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The role of the extracranial venous system in the pathology of central nervous system (CNS) disorders and aging is largely unknown. It is acknowledged that the development of the venous system is subject to many variations and that these variations do not necessarily represent pathological findings. The idea has been changing with regards to the extracranial venous system. DISCUSSION A range of extracranial venous abnormalities have recently been reported, which could be classified as structural/morphological, hemodynamic/functional and those determined only by the composite criteria and use of multimodal imaging. The presence of these abnormalities usually disrupts normal blood flow and is associated with the development of prominent collateral circulation. The etiology of these abnormalities may be related to embryologic developmental arrest, aging or other comorbidities. Several CNS disorders have been linked to the presence and severity of jugular venous reflux. Another composite criteria-based vascular condition named chronic cerebrospinal venous insufficiency (CCSVI) was recently introduced. CCSVI is characterized by abnormalities of the main extracranial cerebrospinal venous outflow routes that may interfere with normal venous outflow. SUMMARY Additional research is needed to better define the role of the extracranial venous system in relation to CNS disorders and aging. The use of endovascular treatment for the correction of these extracranial venous abnormalities should be discouraged, until potential benefit is demonstrated in properly-designed, blinded, randomized and controlled clinical trials.
Collapse
Affiliation(s)
- Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.
| | | |
Collapse
|
15
|
Kramer LA, Cohen AM, Hasan KM, Heimbigner JH, Barreto AD, Brod SA, Narayana PA, Wolinsky JS. Contrast enhanced MR venography with gadofosveset trisodium: Evaluation of the intracranial and extracranial venous system. J Magn Reson Imaging 2013; 40:630-40. [DOI: 10.1002/jmri.24409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 08/09/2013] [Indexed: 11/08/2022] Open
Affiliation(s)
- Larry A. Kramer
- Department of Diagnostic and Interventional Imaging; University of Texas Health Science Center at Houston; Houston Texas USA
| | - Alan M. Cohen
- Department of Diagnostic and Interventional Imaging; University of Texas Health Science Center at Houston; Houston Texas USA
| | - Khader M. Hasan
- Department of Diagnostic and Interventional Imaging; University of Texas Health Science Center at Houston; Houston Texas USA
| | - Jared H. Heimbigner
- Department of Diagnostic and Interventional Imaging; University of Texas Health Science Center at Houston; Houston Texas USA
| | - Andrew D. Barreto
- Department of Neurology; University of Texas Health Science Center at Houston; Houston Texas USA
| | - Staley A. Brod
- Department of Neurology; University of Texas Health Science Center at Houston; Houston Texas USA
| | - Ponnada A. Narayana
- Department of Diagnostic and Interventional Imaging; University of Texas Health Science Center at Houston; Houston Texas USA
| | - Jerry S. Wolinsky
- Department of Neurology; University of Texas Health Science Center at Houston; Houston Texas USA
| |
Collapse
|
16
|
Feng W, Utriainen D, Trifan G, Elias S, Sethi S, Hewett J, Mark Haacke E. Characteristics of flow through the internal jugular veins at cervical C2/C3 and C5/C6 levels for multiple sclerosis patients using MR phase contrast imaging. Neurol Res 2013; 34:802-9. [DOI: 10.1179/1743132812y.0000000079] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Wei Feng
- Department of RadiologyWayne State University, Detroit, MI, USA
| | | | | | - Saba Elias
- Magnetic Resonance InnovationsInc., Detroit, MI, USA
| | - Sean Sethi
- Magnetic Resonance InnovationsInc., Detroit, MI, USA
| | | | - E Mark Haacke
- Department of RadiologyWayne State University, Detroit, MI, USA
- Magnetic Resonance InnovationsInc., Detroit, MI, USA
- Department of Biomedical EngineeringWayne State University, Detroit, MI, USA
- Magnetic Resonance Imaging Institute for Biomedical ResearchDetroit, MI, USA
- Department of Electrical and Computer EngineeringMcMaster University, Hamilton, Ont., Canada
| |
Collapse
|
17
|
Beggs CB, Magnano C, Shepherd SJ, Marr K, Valnarov V, Hojnacki D, Bergsland N, Belov P, Grisafi S, Dwyer MG, Carl E, Weinstock-Guttman B, Zivadinov R. Aqueductal cerebrospinal fluid pulsatility in healthy individuals is affected by impaired cerebral venous outflow. J Magn Reson Imaging 2013; 40:1215-22. [DOI: 10.1002/jmri.24468] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 09/15/2013] [Indexed: 11/11/2022] Open
Affiliation(s)
- Clive B. Beggs
- Medical Biophysics Laboratory; University of Bradford; Bradford UK
| | - Christopher Magnano
- Buffalo Neuroimaging Analysis Center; University at Buffalo; Buffalo New York USA
| | | | - Karen Marr
- Buffalo Neuroimaging Analysis Center; University at Buffalo; Buffalo New York USA
| | - Vesela Valnarov
- Buffalo Neuroimaging Analysis Center; University at Buffalo; Buffalo New York USA
| | - David Hojnacki
- Jacobs MS Comprehensive and Research Center; University at Buffalo; Buffalo New York USA
| | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center; University at Buffalo; Buffalo New York USA
| | - Pavel Belov
- Buffalo Neuroimaging Analysis Center; University at Buffalo; Buffalo New York USA
| | - Steven Grisafi
- Buffalo Neuroimaging Analysis Center; University at Buffalo; Buffalo New York USA
| | - Michael G. Dwyer
- Medical Biophysics Laboratory; University of Bradford; Bradford UK
| | - Ellen Carl
- Medical Biophysics Laboratory; University of Bradford; Bradford UK
| | | | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center; University at Buffalo; Buffalo New York USA
- Jacobs MS Comprehensive and Research Center; University at Buffalo; Buffalo New York USA
| |
Collapse
|
18
|
Farina M, Novelli E, Pagani R. Cross-sectional area variations of internal jugular veins during supine head rotation in multiple sclerosis patients with chronic cerebrospinal venous insufficiency: a prospective diagnostic controlled study with duplex ultrasound investigation. BMC Neurol 2013; 13:162. [PMID: 24188184 PMCID: PMC4229316 DOI: 10.1186/1471-2377-13-162] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 10/28/2013] [Indexed: 02/06/2023] Open
Abstract
Background Normally, chronic cerebrospinal venous insufficiency (CCSVI) has been studied using echo-colour Doppler (ECD). Subjects are examined in the supine and sitting positions, in accordance with a static protocol without rotation of the head. A dynamic approach, to assess venous sizes with different degrees of head rotation, has only been performed to improve jugular venous catheterisation. These echographic studies have suggested that head rotation to the contralateral side increases the cross-sectional area (CSA) of the internal jugular veins (IJVs) in supine subjects. Our goal was to evaluate the behaviour of CSA of the IJVs during supine head rotation in multiple sclerosis (MS) patients with CCSVI, compared to healthy controls (HCs). Methods The IJVs of 313 MS patients with CCSVI (male 43.8%, male/female 137/176; mean age 45 years old, range 19–77 years) and 298 HCs, matched by gender (male 43.6%, male/female 130/168) and age (mean age 46 years old, range 20–79 years), were compared using ECD. Their CSAs were evaluated with the subjects seated in a tiltable chair, first in the supine position at the level of the cricoid cartilage, with the head in a neutral position, and then after contralateral rotation to 90° from midline. Results Significant differences between the jugular CSAs before and after head rotation were observed only in the MS patients for the IJVs with wall collapse (F[6,1215] = 6414.57, p < 0.001), showing on longitudinal scans a typical “hourglass” aspect that we defined as “miopragic”. No significant difference was found in the distribution of these miopragic veins with regard to MS duration. There was a strong association between the CCSVI scores and the complexity of jugular morphological types (Χ2 [9, N = 313] = 75.183, p < 0.001). Wall miopragia was mainly observed in MS patients with SP (59.3%) and PP (70.0%) clinical forms, compared to RR (48.3%) forms (p = 0.015). Conclusion A dynamic ECD approach allowed us to detect IJVs with a significant increase in their CSAs during head rotation, but only in MS subjects. This feature, most likely the expression of congenital wall miopragia, could be secondary to dysregulation of collagen synthesis, but further histochemical studies will be needed to confirm this hypothesis.
Collapse
|
19
|
Zivadinov R, Karmon Y, Dolic K, Hagemeier J, Marr K, Valnarov V, Kennedy CL, Hojnacki D, Carl EM, Hopkins LN, Levy EI, Weinstock-Guttman B, Siddiqui AH. Multimodal noninvasive and invasive imaging of extracranial venous abnormalities indicative of CCSVI: results of the PREMiSe pilot study. BMC Neurol 2013; 13:151. [PMID: 24139135 PMCID: PMC4015359 DOI: 10.1186/1471-2377-13-151] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 10/14/2013] [Indexed: 11/10/2022] Open
Abstract
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. Results The sensitivity of CV + IVUS was 68.4% for the right and 90% for the left IJV and 85.7% for the azygos vein/VVs, compared to venous anomalies detected on DS. Compared to the venous anomalies detected on MRV, the sensitivity of CV + IVUS was 71.4% in right and 100% in left IJVs and 100% in the azygos vein/VVs; however, the specificity was 38.5%, 38.9% and 11.8%, respectively. The sensitivity between the two invasive imaging techniques, used as benchmarks, ranged from 72.7% for the right IJV to 90% for the azygos vein but the IVUS showed a higher rate of venous anomalies than the CV. There was excellent correspondence between identifying collateral veins on MRV and CV. Conclusions Noninvasive DS screening for the detection of venous anomalies indicative of CCSVI may be a reliable approach for identifying patients eligible for further multimodal invasive imaging testing of the IJVs. However, the noninvasive screening methods were inadequate to depict the total amount of azygos vein/VVs anomalies identified with invasive testing. This pilot study, with limited sample size, shows that both a non-invasive and invasive multimodal imaging diagnostic approach should be recommended to depict a range of extracranial venous anomalies indicative of CCSVI. However, lack of invasive testing on the study subjects whose results were negative on the DS screening and of healthy controls, limits further generalizibility of our findings. In addition, the findings from the 2 invasive techniques confirmed the existence of severe extracranial venous anomalies that significantly impaired normal blood outflow from the brain in this group of MS patients.
Collapse
Affiliation(s)
- Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Comparison of Intravascular Ultrasound with Conventional Venography for Detection of Extracranial Venous Abnormalities Indicative of Chronic Cerebrospinal Venous Insufficiency. J Vasc Interv Radiol 2013; 24:1487-98.e1. [DOI: 10.1016/j.jvir.2013.06.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 05/21/2013] [Accepted: 06/08/2013] [Indexed: 11/15/2022] Open
|
21
|
Lupattelli T, Bellagamba G, Righi E, Di Donna V, Flaishman I, Fazioli R, Garaci F, Onorati P. Feasibility and safety of endovascular treatment for chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. J Vasc Surg 2013; 58:1609-18. [PMID: 23948669 DOI: 10.1016/j.jvs.2013.05.108] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 04/17/2013] [Accepted: 05/28/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Chronic cerebrospinal venous insufficiency (CCSVI) is a recently discovered syndrome mainly due to stenoses of internal jugular (IJV) and/or azygos (AZ) veins. The present study retrospectively evaluates the feasibility and safety of endovascular treatment for CCSVI in a cohort of patients with multiple sclerosis (MS). METHODS From September 2010 to October 2012, 1202 consecutive patients were admitted to undergo phlebograpy ± endovascular treatment for CCSVI. All the patients had previously been found positive at color Doppler sonography (CDS) for at least two Zamboni criteria for CCSVI and had a neurologist-confirmed diagnosis of MS. Only symptomatic MS were considered for treatment. Percutaneous transluminal angioplasty was carried out as an outpatient procedure at two different institutes. Primary procedures, regarded as the first balloon angioplasty ever performed for CCSVI, and secondary (reintervention) procedures, regarded as interventions performed after venous disease recurrence, were carried out in 86.5% (1037 of 1199) and 13.5% (162 of 1199) of patients, respectively. Procedural success and complications within 30 days were recorded. RESULTS Phlebography followed by endovascular recanalization was carried out in 1999 patients consisting of 1219 interventions. Balloon angioplasty alone was performed in 1205 out of 1219 (98.9%) procedures, whereas additional stent placement was required in the remaining 14 procedures (1.1%) following unsuccessful attempts at AZ dilatation. No stents were ever implanted in the IJV. The feasibility rate was as high as 99.2% (1209 interventions). Major complications included one (0.1%) AZ rupture occurring during balloon dilatation and requiring blood transfusion, one (0.1%) severe bleeding in the groin requiring open surgery, two (0.2%) surgical openings of the common femoral vein to remove balloon fragments, and three (0.2%) left IJV thromboses. The overall major and minor complication rates at 30 days were 0.6% and 2.5%, respectively. CONCLUSIONS Endovascular treatment for CCSVI appears feasible and safe. However, a proper learning curve can dramatically lower the rate of adverse events. In our experience, the vast majority of complications occurred in the first 400 cases performed.
Collapse
Affiliation(s)
- Tommaso Lupattelli
- Vascular and Endovascular Unit, Istituto Clinico Cardiologico (ICC) Gruppo Villa Maria (GVM) Sanità, Rome, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Benedict RHB, Weinstock-Guttmam B, Marr K, Valnarov V, Kennedy C, Carl E, Brooks C, Hojnacki D, Zivadinov R. Chronic cerebrospinal venous insufficiency is not associated with cognitive impairment in multiple sclerosis. BMC Med 2013; 11:167. [PMID: 23866161 PMCID: PMC3734117 DOI: 10.1186/1741-7015-11-167] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 06/17/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic cerebrospinal venous insufficiency (CCSVI) has been reported in multiple sclerosis (MS) yet its significance in relation to cognitive function is undetermined.This study measured the association between the presence and severity of CCSVI and cognitive impairment in patients with MS. METHODS CCSVI was assessed using extra-cranial and trans-cranial Doppler sonography in 109 MS patients (79 with relapsing-remitting, 23 with secondary-progressive and 7 with primary-progressive disease subtype). A subject was considered CCSVI-positive if ≥2 venous hemodynamic criteria were fulfilled. The Minimal Assessment of Cognitive Function in MS (MACFIMS) battery was administered assessing the full spectrum of cognitive domains known to be affected by MS. Depression was quantified using the Beck Depression Inventory Fast Screen (BDIFS). Partial correlations, analysis of variance (or covariance) and linear regression were used to examine the hypothesis that CCSVI status is related to cognition or depression after controlling for education and gender. RESULTS There were 64 (58.7%) patients who were considered CCSVI-positive. The regression models predicting venous hemodynamic insufficiency severity score were not statistically significant for any of the MACFIMS predictor variables. The analysis of variance tests showed a significant effect of CCSVI-positive diagnosis on cognitive ability in only one of the 10 MACFIMS outcomes, and that one was in the opposite direction of the tested hypothesis. There was no correspondence between CCSVI diagnosis and depression, as measured by the BDIFS. CONCLUSIONS We find no evidence of an association between the presence and severity of CCSVI with cognitive impairment and depression in patients with MS.
Collapse
Affiliation(s)
- Ralph H B Benedict
- Department of Neurology, State University of New York at Buffalo, 100 High St, Buffalo, NY 14203, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Rahman MT, Sethi SK, Utriainen DT, Hewett JJ, Haacke EM. A comparative study of magnetic resonance venography techniques for the evaluation of the internal jugular veins in multiple sclerosis patients. Magn Reson Imaging 2013; 31:1668-76. [PMID: 23850076 DOI: 10.1016/j.mri.2013.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 04/24/2013] [Accepted: 05/30/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The use of magnetic resonance imaging (MRI) to assess the vascular nature of diseases such as multiple sclerosis (MS) is a growing field of research. This work reports on the application of MR angiographic (MRA) and venographic (MRV) techniques in assessing the extracranial vasculature in MS patients. MATERIALS AND METHODS A standardized MRI protocol containing 2D TOF-MRV and dynamic 3D contrast-enhanced (CE) MRAV was run for 170 MS patients and 40 healthy controls (HC). The cross-sectional area (CSA) of the internal jugular veins (IJVs) was measured at three neck levels in all subjects for both MRV techniques to determine the presence of venous stenoses. All data were analyzed retrospectively. RESULTS For the values where both methods showed signal, the 3D method showed larger CSA measurement values compared to 2D methods in both IJVs, in both MS and HC subjects which was confirmed with student paired t-tests. Of the 170 MS patients, 93 (55%) in CE-MRAV and 103 (61%) in TOF-MRV showed stenosis in at least one IJV. The corresponding numbers for the 40 HC subjects were 2 (5%) and 4 (10%), respectively. Carotid ectasias with IJV stenosis were seen in 26 cases (15%) with 3D CE-MRAV and were not observable with 2D TOF-MRV. Carotid ectasias were not seen in the HC group. In the 2D TOF-MRV data, banding of the IJVs related to slow flow was seen in 58 (34%) MS cases and in no HC cases. MS patients showed lower average CSAs than the HC subjects. CONCLUSION The 3D CE MRAV depicted the vascular anatomy more completely than the 2D TOF-MRV. However, the 3D CE MRAV does not provide any information about the flow characteristics which are indirectly available in the 2D TOF-MRV in those cases where there is slow flow.
Collapse
|
24
|
Brod SA, Kramer LA, Cohen AM, Barreto AD, Bui TT, Jemelka JR, Ton K, Lindsey JW, Nelson F, Narayana PA, Wolinsky JS. Chronic cerebrospinal venous insufficiency: masked multimodal imaging assessment. Mult Scler 2013; 19:1499-507. [PMID: 23828872 DOI: 10.1177/1352458513494493] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- Staley A Brod
- Department of Neurology, University of Texas Health Science Center at Houston, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Prevalence of incidental narrowing of the superior segment of the internal jugular vein in patients without multiple sclerosis. Clin Neuroradiol 2013; 24:121-7. [PMID: 23817770 DOI: 10.1007/s00062-013-0232-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 06/12/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Internal jugular vein (IJV) narrowing superiorly is likely relatively frequent. IJV narrowing has been proposed as a potential pathophysiologic component for multiple sclerosis (MS). Our purpose was to investigate the prevalence of incidental superior IJV narrowing in patients imaged with neck computed tomography angiography (CTA) for reasons unrelated to IJV pathology or MS. METHODS We retrospectively identified 164 consecutive adult patients who had undergone neck CTA in which at least one IJV superior segment was opacified (158 right, 155 left IJVs). At the narrowest point of the upper IJV, each IJV was assessed for dominance, graded (shape and narrowing), measured (diameter and area), and located (axially and craniocaudally). Associations were analyzed using Spearman rank correlations (p < 0.05 significant). Medical records were reviewed for MS. RESULTS Among 164 patients, at least one IJV was: absent/pinpoint in 15 % (25/164), occluded/nearly occluded in 26 % (43/164). Shape, narrowing, and the three measurements all correlated with each other (all p < 0.01). Lateral location with respect to C1 transverse foramen correlated with subjectively and objectively smaller IJVs (p < 0.01). The most common craniocaudal location was at the C1 transverse process (79 % (125/158) of right and 81 % (126/155) of left IJVs). No patient had a diagnosis of MS. CONCLUSIONS The appearance of the superior IJV is variable, with an occlusive/near-occlusive appearance present in approximately one-quarter of patients without known MS undergoing CTA. Radiologists should be aware of and cautious to report or ascribe clinical significance to this frequent anatomic variant.
Collapse
|
26
|
Dolic K, Siddiqui AH, Karmon Y, Marr K, Zivadinov R. The role of noninvasive and invasive diagnostic imaging techniques for detection of extra-cranial venous system anomalies and developmental variants. BMC Med 2013; 11:155. [PMID: 23806142 PMCID: PMC3699429 DOI: 10.1186/1741-7015-11-155] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/30/2013] [Indexed: 02/08/2023] Open
Abstract
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 extra-cranial 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.
Collapse
Affiliation(s)
- Kresimir Dolic
- Buffalo Neuroimaging Analysis Center, Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High St, Buffalo, NY 14203, USA
| | | | | | | | | |
Collapse
|
27
|
Endovascular diagnosis and management of chronic cerebrospinal venous insufficiency: retrospective analysis of 30-day morbidity and mortality in 95 consecutive patients. AJR Am J Roentgenol 2013; 200:1358-64. [PMID: 23701076 DOI: 10.2214/ajr.12.8938] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The purpose of this study is to report the 30-day morbidity and mortality associated with the endovascular diagnosis and management of chronic cerebrospinal venous insufficiency. MATERIALS AND METHODS The medical records of 95 consecutive patients (60 women and 35 men) with a mean age of 48 years (age range, 25-66 years) who underwent diagnostic endovascular evaluation and intervention for chronic cerebrospinal venous insufficiency between June 2010 and September 2011 were reviewed retrospectively. All patients had a diagnosis of multiple sclerosis by McDonald criteria. Endovascular evaluation of the internal jugular and azygos veins was performed with digital subtraction venography and intravascular ultrasound. Indications for percutaneous transluminal angioplasty (PTA) were venographic findings of a greater than 50% diameter stenosis, the presence of reflux on digital subtraction venography, greater than 50% cross-sectional area stenosis by intravascular ultra-sound, or a finding of abnormal thick valves or webs by either method. The primary endpoint of this study was the 30-day mortality, and the secondary endpoint was the presence of major complications. Results are presented as means and percentages. RESULTS A total of 107 procedures were performed in 95 patients. Endovascular evaluation showed venous lesions requiring intervention in 90 of 95 patients (94.7%) and was negative in five of 95 patients (5.3%). A total of 193 venous lesions were treated; angioplasty was technically successful in 188 of 193 (97.4%) lesions. Internal jugular vein thrombosis after PTA was identified in three of 95 (3.2%) of the treated patients. Bleeding at the puncture site not requiring transfusion occurred in four of 95 patients (4.2%). There were no reported procedure-related deaths. CONCLUSION The results of the current study suggest that endovascular evaluation and management of chronic cerebrospinal venous insufficiency is safe, with low morbidity and no procedure-related mortality.
Collapse
|
28
|
Beggs C, Shepherd S, Zamboni P. Cerebral venous outflow resistance and interpretation of cervical plethysmography data with respect to the diagnosis of chronic cerebrospinal venous insufficiency. Phlebology 2013; 29:191-99. [PMID: 23060482 DOI: 10.1258/phleb.2012.012039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE While chronic cerebrospinal venous insufficiency (CCSVI) can be characterized using cervical plethysmography, much remains unknown about the haemodynamics associated with this procedure. The aim of the study was therefore to gain a deeper understanding of the observed haemodynamics. METHOD Forty healthy controls and 44 CCSVI patients underwent cervical plethysmography, which involved placing a strain-gauge collar around their necks and tipping them from the upright (90(o)) to supine position (0(o)) in a chair. Once stabilized, they were returned to the upright position, allowing blood to drain from the neck. A mathematical model was used to calculate the hydraulic resistance of the extracranial venous system for each subject in the study. RESULTS The mean hydraulic resistance of the extracranial venous system was 10.28 (standard deviation [SD] 5.14) mmHg.s/mL in the healthy controls and 16.81 (SD 9.22) in the CCSVI patients (P < 0.001). CONCLUSIONS The haemodynamics of the extracranial venous system are greatly altered in CCSVI patients.
Collapse
Affiliation(s)
- C Beggs
- Medical Biophysics Laboratory, University of Bradford, UK
| | | | | |
Collapse
|
29
|
Denislic M, Milosevic Z, Zorc M, Ravnik IZD, Mendiz O. Disability caused by multiple sclerosis is associated with the number of extra cranial venous stenoses: possible improvement by venous angioplasty. Results of a prospective study. Phlebology 2013. [PMID: 23202144 DOI: 10.1258/phleb.2012.012065] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Chronic cerebrospinal venous insufficiency (CCSVI) was recently described in patients with multiple sclerosis (MS). The hypothesis of the vascular aetiology provides a new approach in the investigation and treatment of MS. METHODS Our open-label study included 94 MS patients who fulfilled ultrasound sonographic criteria required for CCSVI. The internal jugular and/or azygous veins by a catheter venography were dilated. RESULTS In 34.8% of the patients unilateral, in 65.2% bilateral venous abnormalities and in 2.1% no luminal obstructions were demonstrated. The patient group with the higher disability score had a significantly higher number of venous lesions (P < 0.005). Significant improvement of clinical disability in relapsing-remitting patients was (P < 0.001) achieved. In our study no stents were used. Re-stenosis occurred in 21.7% of the patients. CONCLUSION The number of venous narrowings is higher in more disabled patients. A significant improvement in clinical disability in the relapsing-remitting group was observed.
Collapse
Affiliation(s)
- M Denislic
- Clinical Centre Ljubljana, Institute of Radiology, Zaloska 7, Slovenia.
| | | | | | | | | |
Collapse
|
30
|
Valdueza JM, Doepp F, Schreiber SJ, van Oosten BW, Schmierer K, Paul F, Wattjes MP. What went wrong? The flawed concept of cerebrospinal venous insufficiency. J Cereb Blood Flow Metab 2013; 33:657-68. [PMID: 23443168 PMCID: PMC3652697 DOI: 10.1038/jcbfm.2013.31] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
In 2006, Zamboni reintroduced the concept that chronic impaired venous outflow of the central nervous system is associated with multiple sclerosis (MS), coining the term of chronic cerebrospinal venous insufficiency ('CCSVI'). The diagnosis of 'CCSVI' is based on sonographic criteria, which he found exclusively fulfilled in MS. The concept proposes that chronic venous outflow failure is associated with venous reflux and congestion and leads to iron deposition, thereby inducing neuroinflammation and degeneration. The revival of this concept has generated major interest in media and patient groups, mainly driven by the hope that endovascular treatment of 'CCSVI' could alleviate MS. Many investigators tried to replicate Zamboni's results with duplex sonography, magnetic resonance imaging, and catheter angiography. The data obtained here do generally not support the 'CCSVI' concept. Moreover, there are no methodologically adequate studies to prove or disprove beneficial effects of endovascular treatment in MS. This review not only gives a comprehensive overview of the methodological flaws and pathophysiologic implausibility of the 'CCSVI' concept, but also summarizes the multimodality diagnostic validation studies and open-label trials of endovascular treatment. In our view, there is currently no basis to diagnose or treat 'CCSVI' in the care of MS patients, outside of the setting of scientific research.
Collapse
Affiliation(s)
- José M Valdueza
- Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany.
| | | | | | | | | | | | | |
Collapse
|
31
|
Zivadinov R, Magnano C, Galeotti R, Schirda C, Menegatti E, Weinstock-Guttman B, Marr K, Bartolomei I, Hagemeier J, Malagoni AM, Hojnacki D, Kennedy C, Carl E, Beggs C, Salvi F, Zamboni P. Changes of cine cerebrospinal fluid dynamics in patients with multiple sclerosis treated with percutaneous transluminal angioplasty: a case-control study. J Vasc Interv Radiol 2013; 24:829-38. [PMID: 23523158 DOI: 10.1016/j.jvir.2013.01.490] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 01/15/2013] [Accepted: 01/18/2013] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To investigate characteristics of cine phase contrast-calculated cerebrospinal fluid (CSF) flow and velocity measures in patients with relapsing-remitting (RR) multiple sclerosis (MS) receiving standard medical treatment who had been diagnosed with chronic cerebrospinal venous insufficiency (CCSVI) and underwent percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS This case-controlled, magnetic resonance (MR) imaging-blinded study included 15 patients with RR MS who presented with significant stenoses (≥50% lumen reduction on catheter venography) in the azygous or internal jugular veins. Eight patients underwent PTA in addition to medical therapy immediately following baseline assessments (case group) and seven had delayed PTA after 6 months of medical therapy alone (control group). CSF flow and velocity measures were quantified over 32 phases of the cardiac cycle by a semiautomated method. Outcomes were compared between groups at baseline and at 6 and 12 months of the study by mixed-effect model analysis. RESULTS At baseline, no significant differences in CSF flow or velocity measures were detected between groups. At month 6, significant improvement in flow (P<.001) and velocity (P = .013) outcomes were detected in the immediate versus the delayed group, and persisted to month 12 (P = .001 and P = .021, respectively). Within-group flow comparisons from baseline to follow-up showed a significant increase in the immediate group (P = .033) but a decrease in the delayed group (P = .024). Altered CSF flow and velocity measures were associated with worsening of clinical and MR outcomes in the delayed group. CONCLUSIONS PTA in patients with MS with CCSVI increased CSF flow and decreased CSF velocity, which are indicative of improved venous parenchyma drainage.
Collapse
Affiliation(s)
- Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, University at Buffalo, Buffalo, NY 14203, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Kostic MS, Rajkovic JS, Floranovic MSP, Dimov ID, Pavlovic DD. Multiple sclerosis and oxidative stress—a clinical perspective. NEUROCHEM J+ 2013. [DOI: 10.1134/s1819712412040083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
33
|
Abstract
OBJECTIVES To analyze all the arguments against chronic cerebrospinal venous insufficiency (CCSVI) as a medical entity, and its association with multiple sclerosis (MS) and to revise all the findings suggesting a possible connection between these two entities. METHODS We revised the methodology and results of all fourteen published studies on prevalence of CCSVI in MS patients. Furthermore, we take into consideration other work dealing with possible causes and explanations of venous, as well as vascular dysfunctions linked with MS. RESULTS Studies of prevalence show a great variability in prevalence of CCSVI in MS patients. However, a recent meta-analysis assessed an over 13 times increased prevalence in MS. Global hypoperfusion of the brain, and reduced cerebral spinal fluid dynamics in MS was shown to be related to CCSVI. Post-mortem studies show a higher prevalence of intraluminal defects in the main extracranial vein in MS patients in respect to controls. DISCUSSION Taking into account the current epidemiological data, the autoptic findings, and the relationship between CCSVI and both hypoperfusion and cerebrospinal fluid flow, CCSVI can be inserted in the list of multiple factors involved in MS pathogenesis. Our careful data analysis may conclude that great variability in prevalence of CCSVI in MS patients can be a result of different methodologies used in venous ultrasound assessment. Finally, it has been proven that CCSVI share the three main risk factors with MS. On the other hand, smoking is the most important risk factor for endothelial cell damage, vitamin D has a protective role and Epstein-Barr virus passes the blood-brain barrier by invading the endothelial cells, therefore, epidemiologically, linking the imbalance of these three factors to MS through autoimmunity.
Collapse
|
34
|
Utriainen D, Trifan G, Sethi S, Elias S, Hewett J, Feng W, Haacke EM. Magnetic resonance imaging signatures of vascular pathology in multiple sclerosis. Neurol Res 2013; 34:780-92. [PMID: 22971468 DOI: 10.1179/1743132812y.0000000078] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Venous vascular contributing factors to multiple sclerosis (MS) have been known for some time. Only recently has the scope of their potential role become more apparent with the theory of chronic cerebrospinal venous insufficiency (CCSVI). As research expands to further explore the role of vascular pathology in the MS population, it is expedient to review the evidence from an imaging perspective. In this paper, we review the current state-of-the-art methods using magnetic resonance imaging (MRI) as applied to imaging MS patients and CCSVI. This includes evaluating imaging signatures of vascular structure and flow as well as brain iron content. Upon review of the literature, we find that extracranial venous anomalies including stenosis, venous malformations, and collateralization of flow in the major veins of the neck have been observed to be prevalent in the MS population. Abnormal flow has been reported in MS patients both in major vessels using phase-contrast flow quantification and in the brain using perfusion-weighted imaging. We discuss the role of quantitative flow imaging and its potential in assessing possible biomarkers for abnormal flow. Finally, it has been suggested that the presence of high iron content may indirectly indicate progression of existing vascular pathology. To that end, we review the use of susceptibility-weighted imaging in monitoring iron in the thalamus, basal ganglia, and MS lesions.
Collapse
|
35
|
McAuliffe W, Kermode AG. Mystery of chronic cerebrospinal venous insufficiency: identical venographic and ultrasound findings in patients with MS and controls. AJNR Am J Neuroradiol 2013; 34:1370-4. [PMID: 23370468 DOI: 10.3174/ajnr.a3390] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Stenosis of the internal jugular, azygos, and other veins detected by using intracranial and neck Doppler and B-mode sonography and confirmed by venography has been reported in MS with a high degree of sensitivity. This article reports the results of sonographic findings in patients with MS and controls, looking for evidence of the controversial entity chronic cerebrospinal venous insufficiency. Furthermore, the venographic appearance in controls is documented. MATERIALS AND METHODS Thirty consecutive patients with definite MS and 10 controls had TCD and high-resolution Doppler sonography of the neck vessels by using the published sonography criteria of Zamboni et al. Those with 2 positive findings consented to undergo contrast digital subtraction venography for delineation of possible venous stenosis. Nine consecutive patients undergoing digital subtraction venography for petrosal venous sampling or parathormone sampling had images of their internal jugular veins obtained as part of their procedure, and they were assessed for stenosis. RESULTS No patient with MS or control had 2 positive sonographic findings; therefore, none were subjected to venography. Of the 9 controls undergoing venography for other reasons, 6 had bilateral IJV narrowing of ≥50%, and 2 others had unilateral narrowing. CONCLUSIONS No difference was detected between patients with MS and controls by using the objective sonographic criteria of Zamboni et al. Furthermore, normal physiologic narrowing is found very commonly in the internal jugular veins in healthy individuals. Nonblinded subjective sonographic assessment of the IJV may erroneously lead to venography, the findings of which may be misinterpreted due to the lack of widespread knowledge about the appearance of these veins in healthy individuals.
Collapse
Affiliation(s)
- W McAuliffe
- Neurological Intervention and Imaging Service of Western Australia, Australian Neuromuscular Research Institute, Sir Charles Gairdner Hospital, Nedlands, Perth, Australia.
| | | |
Collapse
|
36
|
Chronic cerebrospinal venous insufficiency as a cause of multiple sclerosis: controversy and reality. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:203-14. [PMID: 22311713 DOI: 10.1007/s11936-012-0168-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OPINION STATEMENT Multiple sclerosis (MS) is a relapsing and progressive disorder of the central nervous system. It is characterized most commonly by episodes of clinical worsening, followed by clinical improvement. Pathologically, MS is associated with focal areas of myelin destruction, inflammation, and axonal transection ("demyelinating plaques") in the brain and spinal cord. Traditionally, MS has been considered an autoimmune disorder, with the primary pathophysiology arising from an errant immune system. Recent work has raised the possibility that MS is not caused primarily by an immune abnormality but may instead arise from venous anomalies affecting the jugular and/or azygos venous systems. This condition has been called chronic cerebrospinal venous insufficiency (CCSVI). It has been proposed that CCSVI may be pathogenic in MS, causing venous back pressure and iron deposition, with a secondary immune response. Some investigators have proceeded to unblinded nonrandomized angioplasty and stenting procedures in patients with CCSVI, with anecdotal reports of symptom improvement. Because of conflicting data on the presence of CCSVI and the absence of controlled trials of CCSVI intervention, the current standard of clinical care is neither to evaluate multiple sclerosis (MS) patients for CCSVI anomalies, nor to intervene with procedures to alter such anomalies. There is intense interest and ongoing work to evaluate the presence of venous anomalies in MS patients as well as in normal controls and patients with other neurologic conditions; to characterize such anomalies, if present; and to further understand whether the concept of a "backpressure" pathology is borne out by the evidence. If CCSVI is indeed a pathogenic mechanism for some subset of the MS population, this would dramatically change the focus of attention for therapeutic endeavors and monitoring for this population and would bring MS therapeutics firmly into the area of vascular intervention. On the other hand, the history of MS research contains many novel and potentially paradigm-shifting ideas that were later disproved by other investigators.
Collapse
|
37
|
Ultrasound applications in critical care medicine. Crit Care Res Pract 2012; 2012:382615. [PMID: 22844586 PMCID: PMC3401525 DOI: 10.1155/2012/382615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 06/10/2012] [Indexed: 11/26/2022] Open
|
38
|
Utriainen D, Feng W, Elias S, Latif Z, Hubbard D, Haacke EM. Using Magnetic Resonance Imaging as a Means to Study Chronic Cerebral Spinal Venous Insufficiency in Multiple Sclerosis Patients. Tech Vasc Interv Radiol 2012; 15:101-12. [DOI: 10.1053/j.tvir.2012.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
39
|
Zivadinov R, Cutter G, Marr K, Ramanathan M, Benedict RHB, Bergsland N, Morgan C, Carl E, Hojnacki D, Yeh EA, Willis L, Cherneva M, Kennedy C, Dwyer MG, Weinstock-Guttman B. No association between conventional brain MR imaging and chronic cerebrospinal venous insufficiency in multiple sclerosis. AJNR Am J Neuroradiol 2012; 33:1913-7. [PMID: 22576891 DOI: 10.3174/ajnr.a3112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CCSVI has been reported to occur at high frequency in MS. Its significance in relation to MR imaging parameters also needs to be determined, both in patients with MS and HCs. Therefore, this study determined the associations of CCSVI and conventional MR imaging outcomes in patients with MS and in HCs. MATERIALS AND METHODS T2, T1, and gadolinium lesion number, LV, and brain atrophy were assessed on 3T MR imaging in 301 subjects, of whom 162 had RRMS, 66 had secondary-progressive MS subtype, and 73 were HCs. CCSVI was assessed using extracranial and transcranial Doppler evaluation. The MR imaging measure differences were explored with 27 borderline cases for CCSVI, added to both the negative and positive CCSVI groups to assess sensitivity of the results of these cases. RESULTS No significant differences between subjects with and without CCSVI were found in any of the individual diagnostic subgroups or MS disease subtypes for lesion burden and atrophy measures, independently of the CCSVI classification criteria used, except for a trend for higher T2 lesion number (irrespective of how borderline cases were classified) and lower brain volume (when borderline cases were included in the positive group) in patients with RRMS with CCSVI. No CCSVI or MR imaging differences were found between 26 HCs with, or 47 without, a familial relationship. CONCLUSIONS CCSVI is not associated with more severe lesion burden or brain atrophy in patients with MS or in HCs.
Collapse
Affiliation(s)
- R Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, School of Medicine and Biomedical Sciences, Buffalo, NY 14203, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Haacke EM, Feng W, Utriainen D, Trifan G, Wu Z, Latif Z, Katkuri Y, Hewett J, Hubbard D. Patients with multiple sclerosis with structural venous abnormalities on MR imaging exhibit an abnormal flow distribution of the internal jugular veins. J Vasc Interv Radiol 2012; 23:60-8.e1-3. [PMID: 22221473 DOI: 10.1016/j.jvir.2011.09.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 09/15/2011] [Accepted: 09/17/2011] [Indexed: 10/14/2022] Open
Abstract
PURPOSE To evaluate extracranial venous structural and flow characteristics in patients with multiple sclerosis (MS). MATERIALS AND METHODS Two hundred subjects with MS from two sites (n = 100 each) were evaluated with magnetic resonance (MR) imaging at 3 T. Contrast-enhanced time-resolved MR angiography and time-of-flight MR venography were used to assess vascular anatomy. Two-dimensional phase-contrast MR imaging was used to quantify blood flow. The MS population was divided into two groups: those with evident internal jugular vein (IJV) stenoses (stenotic group) and those without (nonstenotic group). RESULTS Of the 200 patients, 136 (68%) showed IJV structural abnormalities, including unilateral or bilateral stenoses at different levels in the neck (n = 101; 50.5%) and atresia (n = 35; 17.5%). The total IJV flow normalized to the total arterial flow of the stenotic group (56% ± 22) was significantly lower than that of the nonstenotic group (77% ± 14; P < .001). The arterial/venous flow mismatch in the stenotic group (12% ± 15) was significantly greater than that in the nonstenotic group (6% ± 12; P < .001). The ratio of subdominant venous flow rate (Fsd) to dominant venous flow rate (Fd) for the stenotic group (0.38 ± 0.27) was significantly lower than for the nonstenotic group (0.59 ± 0.23; P < .001). The majority of the stenotic group (67%) also had an Fsd of less than 3 mL/s, a Fd/Fsd ratio greater than 3:1, and/or a total IJV flow rate of less than 8 mL/s. CONCLUSIONS MR imaging provides a noninvasive means to separate stenotic from nonstenotic MS cases. The former group was more prevalent in the present MS population and carried significantly less flow in the IJVs than the latter.
Collapse
Affiliation(s)
- E Mark Haacke
- Department of Biomedical Engineering, Wayne State University, Detroit, MI 48201, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Zamboni P, Menegatti E, Conforti P, Shepherd S, Tessari M, Beggs C. Assessment of cerebral venous return by a novel plethysmography method. J Vasc Surg 2012; 56:677-85.e1. [PMID: 22521804 DOI: 10.1016/j.jvs.2012.01.074] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 01/25/2012] [Accepted: 01/26/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Magnetic resonance imaging and echo color Doppler (ECD) scan techniques do not accurately assess the cerebral venous return. This generated considerable scientific controversy linked with the diagnosis of a vascular syndrome known as chronic cerebrospinal venous insufficiency (CCSVI) characterized by restricted venous outflow from the brain. The purpose of this study was to assess the cerebral venous return in relation to the change in position by means of a novel cervical plethysmography method. METHODS This was a single-center, cross-sectional, blinded case-control study conducted at the Vascular Diseases Center, University of Ferrara, Italy. The study involved 40 healthy controls (HCs; 18 women and 22 men) with a mean age of 41.5 ± 14.4 years, and 44 patients with multiple sclerosis (MS; 25 women and 19 men) with a mean age of 41.0 ± 12.1 years. All participants were previously scanned using ECD sonography, and further subset in HC (CCSVI negative at ECD) and CCSVI groups. Subjects blindly underwent cervical plethysmography, tipping them from the upright (90°) to supine position (0°) in a chair. Once the blood volume stabilized, they were returned to the upright position, allowing blood to drain from the neck. We measured venous volume (VV), filling time (FT), filling gradient (FG) required to achieve 90% of VV, residual volume (RV), emptying time (ET), and emptying gradient (EG) required to achieve 90% of emptying volume (EV) where EV = VV - RV, also analyzing the considered parameters by receiver operating characteristic (ROC) curves and principal component mathematical analysis. RESULTS The rate at which venous blood discharged in the vertical position (EG) was significantly faster in the controls (2.73 mL/second ± 1.63) compared with the patients with CCSVI (1.73 mL/second ± 0.94; P = .001). In addition, respectively, in controls and in patients with CCSVI, the following parameters were highly significantly different: FT 5.81 ± 1.99 seconds vs 4.45 ± 2.16 seconds (P = .003); FG 0.92 ± 0.45 mL/second vs 1.50 ± 0.85 mL/second (P < .001); RV 0.54 ± 1.31 mL vs 1.37 ± 1.34 mL (P = .005); ET 1.84 ± 0.54 seconds vs 2.66 ± 0.95 seconds (P < .001). Mathematical analysis demonstrated a higher variability of the dynamic process of cerebral venous return in CCSVI. Finally, ROC analysis demonstrated a good sensitivity of the proposed test with a percent concordant 83.8, discordant 16.0, tied 0.2 (C = 0.839). CONCLUSIONS Cerebral venous return characteristics of the patients with CCSVI were markedly different from those of the controls. In addition, our results suggest that cervical plethysmography has great potential as an inexpensive screening device and as a postoperative monitoring tool.
Collapse
Affiliation(s)
- Paolo Zamboni
- Vascular Diseases Centre, University of Ferrara, Ferrara, Italy.
| | | | | | | | | | | |
Collapse
|
42
|
McTaggart RA, Fischbein NJ, Elkins CJ, Hsiao A, Cutalo MJ, Rosenberg J, Dake MD, Zaharchuk G. Extracranial venous drainage patterns in patients with multiple sclerosis and healthy controls. AJNR Am J Neuroradiol 2012; 33:1615-20. [PMID: 22517280 DOI: 10.3174/ajnr.a3097] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CCSVI hypothesizes an association between impaired extracranial venous drainage and MS. Published sonographic criteria for CCSVI are controversial, and no MR imaging data exist to support the CCSVI hypothesis. Our purpose was to evaluate possible differences in the extracranial venous drainage of MS and healthy controls using both TOF and contrast-enhanced TRICKS MRV. MATERIALS AND METHODS Healthy subjects (n = 20) and patients with MS (n = 19) underwent axial 2D-TOF neck MRV (to assess flattening) and TRICKS MRV (to assess collaterals) at 3T. Two neuroradiologists blinded to cohort status scored IJV flattening and the severity of non-IJV collaterals by using a 4-point qualitative scale (normal = 0, mild = 1, moderate = 2, severe = 3). κ was used to assess reader agreement. Comparisons between groups were performed by using the Wilcoxon rank sum test. The Spearman rank correlation was used to assess the relationship between IJV flattening and collateral scores and, in patients with MS, EDSS scores. RESULTS The 2 groups were matched for age and sex (MS, 45 ± 8 years, 79% female; healthy controls, 47 ± 10 years, 65% female). Reader agreement for IJV flattening and collateral severity was good (κ = 0.74) and moderate (κ = 0.58), respectively. While IJV flattening was seen in both patients with MS and healthy controls, scores for the patients with MS were significantly higher (P = .002). Despite a trend, there was no significant difference in collateral scores between groups (P = .063). There was a significant positive correlation between flattening and collateral scores (ρ = 0.32, P = .005) and EDSS and flattening scores (ρ = 0.45, P = .004) but not between EDSS and collateral scores (ρ = 0.01, P = .97). CONCLUSIONS These results indicate that patients with MS have greater IJV flattening and a trend toward more non-IJV collaterals than healthy subjects. The role that this finding plays in the pathogenesis or progression of MS, if any, requires further study.
Collapse
Affiliation(s)
- R A McTaggart
- Department of Radiology, Stanford University, Stanford University Medical Center, Stanford, CA 94305, USA.
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Dolic K, Marr K, Valnarov V, Dwyer MG, Carl E, Karmon Y, Kennedy C, Brooks C, Kilanowski C, Hunt K, Siddiqui AH, Hojnacki D, Weinstock-Guttman B, Zivadinov R. Intra- and extraluminal structural and functional venous anomalies in multiple sclerosis, as evidenced by 2 noninvasive imaging techniques. AJNR Am J Neuroradiol 2011; 33:16-23. [PMID: 22194367 DOI: 10.3174/ajnr.a2877] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Chronic cerebrospinal venous insufficiency (CCSVI) is a vascular condition characterized by anomalies of the main extracranial cerebrospinal venous routes that interfere with normal venous outflow. Research into CCSVI will determine its sensitivity and specificity for a diagnosis of MS, its prevalence in MS patients, and its clinical, MRI, and genetic correlates. Our aim was to investigate the prevalence and number of intra- and extraluminal structural and functional extracranial venous abnormalities by using DS and MRV, in patients with MS and HCs. MATERIALS AND METHODS One hundred fifty patients with MS, 104 (69.3%) with RR and 46 (30.7%) with a progressive MS course, and 63 age- and sex-matched HCs were scanned with 3T MR imaging by using TOF and TRICKS sequences (only patients with MS). All subjects underwent DS examination for intra- and extraluminal structural and functional abnormalities of the IJVs. Absent/pinpoint IJV flow morphology on MRV was considered an abnormal finding. Prominence of collateral extracranial veins was assessed with MRV. RESULTS Patients with MS had a significantly higher number of functional (P < .0001), total (P = .001), and intraluminal (P = .005) structural IJV DS abnormalities than HCs. There was a trend for more patients with MS with extraluminal IJV DS abnormalities (P = .023). No significant differences were found on the MRV IJV flow morphology scale between patients with MS and HCs. Patients with progressive MS showed more extraluminal IJV DS abnormalities (P = .01) and more MRV flow abnormalities on TOF (P = .006) and TRICKS (P = .01) than patients with nonprogressive MS. There was a trend for a higher number of collateral veins in patients with MS than in HCs (P = .016). CONCLUSIONS DS is more sensitive than MRV in detecting intraluminal structural and functional venous abnormalities in patients with MS compared with HCs, whereas MRV is more sensitive in showing collaterals.
Collapse
Affiliation(s)
- K Dolic
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Nicolaides AN, Morovic S, Menegatti E, Viselner G, Zamboni P. Screening for chronic cerebrospinal venous insufficiency (CCSVI) using ultrasound: recommendations for a protocol. FUNCTIONAL NEUROLOGY 2011; 26:229-248. [PMID: 22364944 PMCID: PMC3814564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Chronic cerebrospinal venous insufficiency (CCSVI) is a syndrome characterized by stenoses or obstructions of the internal jugular and/or azygos veins with disturbed flow and formation of collateral venous channels. Ultrasound and venographic studies of the internal jugular and azygos venous systems in patients with multiple sclerosis (MS) have demonstrated a high prevalence of CCSVI (mean 71%, range 0-100%; n=1336) associated with activation of collaterals. By contrast, ultrasound and venographic examinations of normal controls and patients without MS have demonstrated a much lower prevalence (mean 7.1%, range 0-22%; n=505). Ultrasound in the form of duplex scanning uses a combination of physiological measurements as well as anatomical imaging and has been used for the detection of CCSVI by different centers with variable results. A high prevalence of obstructive lesions, ranging from 62% to 100%, has been found by some teams in patients with MS compared with a low prevalence (0-25%) in controls. However, others have reported absence of these lesions or a lower prevalence (16-52%). This variability could be the result of differences in technique, training, experience or criteria used. In order to ensure a high reproducibility of duplex scanning with comparable accuracy between centers a detailed protocol with standard methodology and criteria is needed. Also, standardization of the method of reporting of duplex measurements and other findings will facilitate validation of the proposed criteria by different centers. The aim of this document is to produce recommendations for such a protocol and indicate what future research is needed in order to address areas of uncertainty.
Collapse
Affiliation(s)
| | | | | | - Gisel Viselner
- IRCCS C. Mondino National Institute of Neurology Foundation, Department of Neuroradiology University of Pavia, Italy
| | - Paolo Zamboni
- Vascular Disease Center, University of Ferrara, Italy
| |
Collapse
|
45
|
Dake MD, Zivadinov R, Haacke EM. Chronic cerebrospinal venous insufficiency in multiple sclerosis: a historical perspective. FUNCTIONAL NEUROLOGY 2011; 26:181-95. [PMID: 22364939 PMCID: PMC3814562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Chronic cerebrospinal venous insufficiency (CCSVI) is a term used to describe impaired venous drainage from the central nervous system (CNS) caused by abnormalities in anatomy and flow affecting the extracranial veins. Recently, it has been proposed that CCSVI may contribute to the pathogenesis of multiple sclerosis (MS). It is hypothesized that venous obstruction results in abnormal flow that promotes inflammation at the blood-brain barrier and that this triggers a process marked by a disturbance of homeostasis within the CNS that leads to demyelination and neurodegeneration. The venous abnormalities of CCSVI are often diagnosed by ultrasound or magnetic resonance venography, however the prevalence of CCSVI detailed in groups of MS patients and patients without MS varies widely in published reports. Increased standardization of diagnostic studies to evaluate both anatomical and physiological findings associated with CCSVI is needed. The purpose of this article is to provide a background to understand the development of the theory of CCSVI and to frame the relevant issues regarding its diagnosis and relationship to the pathogenesis of MS.
Collapse
Affiliation(s)
- Michael D Dake
- Department of Cardiothoracic Surgery, Standford University School of Medicine, Stanford, CA 94305-5407, USA.
| | | | | |
Collapse
|
46
|
Dolic K, Marr K, Valnarov V, Dwyer MG, Carl E, Hagemeier J, Kennedy C, Brooks C, Kilanowski C, Hunt K, Hojnacki D, Weinstock-Guttman B, Zivadinov R. Sensitivity and specificity for screening of chronic cerebrospinal venous insufficiency using a multimodal non-invasive imaging approach in patients with multiple sclerosis. FUNCTIONAL NEUROLOGY 2011; 26:205-214. [PMID: 22364941 PMCID: PMC3814559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The aim of this study was to investigate whether a combination of Doppler sonography (DS) and magnetic resonance venography (MRV) on 3T MRI increases specificity for detection of chronic cerebrospinal venous insufficiency (CCSVI) in 171 (113 relapsing-remitting, 47 secondary-progressive, 11 primary progressive) patients with multiple sclerosis (MS) and 79 age- and sex matched healthy controls (HCs). One hundred ten (64.3%) MS patients and 30 (38%) HCs presented ≥2 venous hemodynamic CCSVI criteria (p<.0001). Both DS and MRV showed relatively high specificity but lower sensitivity for determining a CCSVI diagnosis in patients with MS vs HCs and between MS subgroups. In MS patients this diagnostic specificity increased to over 90% by combining internal jugular vein and vertebral vein abnormal DS and MRV findings, reflux in deep cerebral veins and MRV findings of >1 collateral veins. This study suggests that a multimodal non-invasive approach (DS and MRV) increases the specificity for a diagnosis of CCSVI in patients with MS.
Collapse
Affiliation(s)
- Kresimir Dolic
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
| | - Karen Marr
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
| | - Vesela Valnarov
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
| | - Michael G. Dwyer
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
| | - Ellen Carl
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
| | - Jesper Hagemeier
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
| | - Cheryl Kennedy
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
| | - Christina Brooks
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
| | - Colleen Kilanowski
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
| | - Kristin Hunt
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
| | - David Hojnacki
- The Jacobs Neurological Institute, Department of Neurology, State University of New York, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- The Jacobs Neurological Institute, Department of Neurology, State University of New York, Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, NY, USA
- The Jacobs Neurological Institute, Department of Neurology, State University of New York, Buffalo, NY, USA
| |
Collapse
|
47
|
Zivadinov R, Ramanathan M, Dolic K, Marr K, Karmon Y, Siddiqui AH, Benedict RHB, Weinstock-Guttman B. Chronic cerebrospinal venous insufficiency in multiple sclerosis: diagnostic, pathogenetic, clinical and treatment perspectives. Expert Rev Neurother 2011; 11:1277-1294. [DOI: 10.1586/ern.11.117] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
48
|
Abstract
Three types of vascular dysfunction have been described in multiple sclerosis (MS). First, findings from epidemiological studies suggest that patients with MS have a higher risk for ischaemic stroke than people who do not have MS. The underlying mechanism is unknown, but might involve endothelial dysfunction secondary to inflammatory disease activity and increased plasma homocysteine concentrations. Second, patients with MS have global cerebral hypoperfusion, which might predispose them to the development of ischaemic stroke. The widespread decrease in perfusion in normal-appearing white matter and grey matter in MS seems not to be secondary to axonal degeneration, but might be a result of reduced axonal activity, reduced astrocyte energy metabolism, and perhaps increased blood concentrations of endothelin-1. Data suggest that a subtype of focal MS lesions might have an ischaemic origin, and there seems to be a link between reduced white matter perfusion and cognitive dysfunction in MS. Third, the pathology of MS might be the consequence of a chronic state of impaired venous drainage from the CNS, for which the term chronic cerebrospinal venous insufficiency (CCSVI) has been coined. A number of recent vascular studies do not support the CCSVI theory, but some elements of CCSVI might be explained by slower cerebral venous blood flow secondary to the reduced cerebral perfusion in patients with MS compared with healthy individuals.
Collapse
Affiliation(s)
- Miguel D'haeseleer
- Department of Neurology, Universitair Ziekenhuis Brussel, Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium.
| | | | | | | |
Collapse
|
49
|
Waschbisch A, Manzel A, Linker RA, Lee DH. Vascular pathology in multiple sclerosis: mind boosting or myth busting? EXPERIMENTAL & TRANSLATIONAL STROKE MEDICINE 2011; 3:7. [PMID: 21756314 PMCID: PMC3156723 DOI: 10.1186/2040-7378-3-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 07/14/2011] [Indexed: 01/15/2023]
Abstract
The investigation of central nervous system vascular changes in the pathophysiology of multiple sclerosis (MS) is a time-honored concept. Yet, recent reports on changes in venous cerebrospinal outflow, the advent of new magnetic resonance imaging techniques and the investigation of immunomodulatory properties of several vascular mediators on the molecular level have added new excitement to hypotheses centering around vascular pathology as determining factor in the pathophysiology of MS. Here we critically review the concept of chronic cerebrospinal venous insufficiency in MS patients and describe new imaging techniques including perfusion weighted imaging, susceptibility weighted imaging and diffusion weighted imaging which reveal central nervous system hypoperfusion, perivascular iron deposition and diffuse structural changes in the MS brain. On a molecular basis, vascular mediators represent interesting targets connecting vascular pathology with immunomodulation. In summary, the relation of venous changes to the pathophysiology of MS may not be as simple as initially described and it certainly seems awkward to think of the complex disease MS solely as result of a simple venous outflow obstruction. Yet, the investigation of new vascular concepts as one variable in the pathophysiology of the autoimmune attack seems very worthwhile and may add to a better understanding of this devastating disorder.
Collapse
Affiliation(s)
- Anne Waschbisch
- Department of Neurology, Schwabachanlage 6, 91054 Erlangen, Germany.
| | | | | | | |
Collapse
|
50
|
Weinstock-Guttman B, Zivadinov R, Cutter G, Tamaño-Blanco M, Marr K, Badgett D, Carl E, Elfadil M, Kennedy C, Benedict RHB, Ramanathan M. Chronic cerebrospinal vascular insufficiency is not associated with HLA DRB1*1501 status in multiple sclerosis patients. PLoS One 2011; 6:e16802. [PMID: 21340025 PMCID: PMC3038867 DOI: 10.1371/journal.pone.0016802] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 12/29/2010] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Chronic cerebrospinal venous insufficiency (CCSVI) was described as a vascular condition characterized by anomalies of veins outside the skull was reported to be associated with multiple sclerosis (MS). The objective was to assess the associations between HLA DRB1*1501 status and the occurrence of CCSVI in MS patients. METHODOLOGY/PRINCIPAL FINDINGS This study included 423 of 499 subjects enrolled in the Combined Transcranial and Extracranial Venous Doppler Evaluation (CTEVD) study. The HLA DRB1*1501 status was obtained in 268 MS patients and 155 controls by genotyping rs3135005, a SNP associated with DRB1*1501 status. All subjects underwent a clinical examination and Doppler scan of the head and neck. The frequency of CCSVI was higher (OR = 4.52, p<0.001) in the MS group 56.0% vs. 21.9% in the controls group and also higher in the progressive MS group 69.8% vs. 49.5% in the non-progressive MS group. The 51.9% frequency of HLA DRB1*1501 positivity (HLA(+)) in MS was higher compared (OR = 2.33, p<0.001) to 31.6% to controls. The HLA(+) frequency in the non-progressive (51.6%) and progressive MS groups (52.3%) was similar. The frequency of HLA(+) CCSVI(+) was 40.7% in progressive MS, 27.5% in non-progressive MS and 8.4% in controls. The presence of CCSVI was independent of HLA DRB1*1501 status in MS patients. CONCLUSIONS/SIGNIFICANCE The lack of strong associations of CCSVI with HLA DRB1*1501 suggests that the role of the underlying associations of CCSVI in MS should be interpreted with caution. Further longitudinal studies should determine whether interactions between these factors can contribute to disease progression in MS.
Collapse
Affiliation(s)
- Bianca Weinstock-Guttman
- Department of Neurology, State University of New York, Buffalo, New York, United States of America
| | - Robert Zivadinov
- Department of Neurology, State University of New York, Buffalo, New York, United States of America
- Department of Neurology, Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, New York, United States of America
| | - Gary Cutter
- Department of Biostatistics, University of Alabama, Birmingham, Alabama, United States of America
| | - Miriam Tamaño-Blanco
- Department of Pharmaceutical Sciences, State University of New York, Buffalo, New York, United States of America
| | - Karen Marr
- Department of Neurology, Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, New York, United States of America
| | - Darlene Badgett
- Department of Pharmaceutical Sciences, State University of New York, Buffalo, New York, United States of America
| | - Ellen Carl
- Department of Neurology, Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, New York, United States of America
| | - Makki Elfadil
- Department of Neurology, Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, New York, United States of America
| | - Cheryl Kennedy
- Department of Neurology, Buffalo Neuroimaging Analysis Center, State University of New York, Buffalo, New York, United States of America
| | - Ralph H. B. Benedict
- Department of Neurology, State University of New York, Buffalo, New York, United States of America
| | - Murali Ramanathan
- Department of Neurology, State University of New York, Buffalo, New York, United States of America
- Department of Pharmaceutical Sciences, State University of New York, Buffalo, New York, United States of America
| |
Collapse
|