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Yang J, Zhang N, Ding C, He X, Li M, Meng W, Ouyang T. Association between chronic cerebrospinal venous insufficiency and multiple sclerosis: a systematic review and meta-analysis. BMJ Open 2023; 13:e072319. [PMID: 37380203 PMCID: PMC10410874 DOI: 10.1136/bmjopen-2023-072319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/18/2023] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVES Numerous studies have indicated that chronic cerebrospinal venous insufficiency is a potential factor in causing multiple sclerosis in recent years, but this conclusion remains unconfirmed. This meta-analysis examined the correlation between multiple sclerosis and chronic cerebrospinal venous insufficiency. METHODS We searched Embase and Medline (Ovid) for publications published from 1 January 2006 to 1 May 2022. The meta-analysis was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Eligible studies (n=20) included 3069 participants from seven countries. Pooled analysis indicated that chronic cerebrospinal venous insufficiency was more frequent in patients with multiple sclerosis than in healthy controls (OR 3.36; 95% CI 1.92 to 5.85; p<0.001) with remarkable heterogeneity among studies (I2=79%). Results were more strongly correlated in subsequent sensitivity analyses, but heterogeneity was also more substantial. We removed studies that initially proposed a chronic cerebrospinal venous insufficiency team as well as studies by authors involved in or advocating endovascular therapies. CONCLUSIONS Chronic cerebrospinal venous insufficiency is significantly associated with multiple sclerosis and it is more prevalent in patients with multiple sclerosis than in healthy individuals, but considerable heterogeneity of results is still observed.
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Affiliation(s)
- Jun Yang
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Na Zhang
- Department of Neurology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Cong Ding
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xiuying He
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Meihua Li
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wei Meng
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Taohui Ouyang
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Song SY, Lan D, Jiao BL, Liu YH, Ding YC, Ji XM, Meng R. The Negative Prognostic Role of Inflammatory Biomarkers in Patients With Chronic Cerebrospinal Venous Insufficiency. Neurologist 2023; 28:57-68. [PMID: 35697039 PMCID: PMC9977416 DOI: 10.1097/nrl.0000000000000443] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The pathologic consequences of inflammatory responses in chronic cerebrospinal venous insufficiency (CCSVI) remains poorly understood. Hence, this study was aimed to evaluate the peripheral inflammatory biomarkers in patients with intracranial and extracranial CCSVI pathology. In addition, the relationship between inflammatory cytokine profile and CCSVI prognosis was also evaluated. METHODS Patients diagnosed with CCSVI between July 2017 and July 2019 were included and subsequently divided into 3 groups based on the location of stenosis. The inflammatory biomarker assay included neutrophil-to-lymphocyte ratios (NLRs), platelet-to-lymphocyte ratios (PLRs), red blood cell distribution widths (RDW), C-reactive protein (CRP) levels, interleukin-6 (IL-6) levels, and neuron-specific enolase levels. Clinical outcomes were assessed using the modified Rankin Scale and Patient Global Impression of Change score. Univariate and multivariate regression analyses were performed to identify significant prognostic factors for poorer outcomes. Finally, we established a nomogram based on the multivariate regression analysis. RESULTS We enrolled 248 patients in total, including 102 males and 146 females, with an average age of 57.85±12.28 years. Compared with patients with internal jugular vein stenosis, cerebral venous sinus stenosis (CVSS) patients were mostly younger and had been suffering from headaches and severe papilledema. Higher levels of NLR, RDW, and CRP were also observed in the CVSS group. Multivariate analysis indicated that NLR, PLR, and IL-6 were the independent prognostic factors for poor CCSVI outcomes. CONCLUSIONS The clinical presentations and increases in NLR, PLR, IL-6, and CRP levels could be distinctly marked in patients with CVSS-related CCSVI than that in internal jugular vein stenosis-related CCSVI, indicating poor prognostic outcomes in these patients. A proinflammatory state might be associated with CCSVI pathology.
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Affiliation(s)
- Si-ying Song
- Departments of Neurology
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing
| | - Duo Lan
- Departments of Neurology
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing
| | - Bao-lian Jiao
- Departments of Neurology
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing
| | - Yun-huan Liu
- Departments of Neurology
- HuaDong Hospital, Fudan University, Shanghai, China
| | - Yu-chuan Ding
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI
| | - Xun-ming Ji
- Departments of Neurology
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing
| | - Ran Meng
- Departments of Neurology
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing
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Lashch NY, Pavlicov AE. [Changes in venous circulation in patients with multiple sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:22-28. [PMID: 37560830 DOI: 10.17116/jnevro202312307222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Multiple sclerosis (MS) is a common neurological disease, especially among people of young working age, and the number of MS cases registered in the world and in the Russian Federation tends to increase. The pathogenesis of MS is based on the theory of damage to its own myelin sheath as a result of activation of autoreactive T cells, which also leads to damage to both oligodendrocytes and axons. In addition, the role of vascular factor in the pathogenesis of MS is discussed in the literature periodically and several areas of research of vascular dysfunction in patients are identified. This article provides a retrospective analysis of the available literature dating from the 19th century to the present time in order to find the relationship between MS and changes in venous circulation.
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Affiliation(s)
- N Y Lashch
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A E Pavlicov
- Pirogov Russian National Research Medical University, Moscow, Russia
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Gandhi S, Marr K, Mancini M, Caprio MG, Jakimovski D, Chandra A, Hagemeier J, Hojnacki D, Kolb C, Weinstock-Guttman B, Zivadinov R. No association between variations in extracranial venous anatomy and clinical outcomes in multiple sclerosis patients over 5 years. BMC Neurol 2019; 19:121. [PMID: 31185944 PMCID: PMC6560860 DOI: 10.1186/s12883-019-1350-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 05/31/2019] [Indexed: 01/08/2023] Open
Abstract
Background No longitudinal, long-term, follow-up studies have explored the association between presence and severity of variations in extracranial venous anatomy, and clinical outcomes in patients with multiple sclerosis (MS). Objective This prospective 5-year follow-up study assessed the relationship of variations in extracranial venous anatomy, indicative of chronic cerebrospinal venous insufficiency (CCSVI) on Doppler sonography, according to the International Society for Neurovascular Disease (ISNVD) proposed consensus criteria, with clinical outcomes and disease progression in MS patients. Methods 90 MS patients (52 relapsing-remitting, RRMS and 38 secondary-progressive, SPMS) and 38 age- and sex-matched HIs were prospectively followed for 5.5 years. Extracranial and transcranial Doppler-based venous hemodynamic assessment was conducted at baseline and follow-up to determine the extent of variations in extracranial venous anatomy. Change in Expanded Disability Status Scale (∆EDSS), development of disability progression (DP) and annualized relapse rate (ARR) were assessed. Results No significant differences were observed in MS patients, based on their presence of variations in extracranial venous anatomy at baseline or at the follow-up, in ∆EDSS, development of DP or ARR. While more MS patients had ISNVD CCSVI criteria fulfilled at baseline compared to HIs (58% vs. 37%, p = 0.03), no differences were found at the 5-year follow-up (61% vs. 56%, p = 0.486). Discussion This is the longest follow-up study assessing the longitudinal relationship between the presence of variations in extracranial venous anatomy and clinical outcomes in MS patients. Conclusion: The presence of variations in extracranial venous anatomy does not influence clinical outcomes over the 5-year follow-up in MS patients. Electronic supplementary material The online version of this article (10.1186/s12883-019-1350-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sirin Gandhi
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Karen Marr
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Marcello Mancini
- Institute of Biostructure and Bioimaging, National Research Council of Italy, Rome, Italy
| | - Maria Grazia Caprio
- Institute of Biostructure and Bioimaging, National Research Council of Italy, Rome, Italy
| | - Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Avinash Chandra
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Jesper Hagemeier
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - David Hojnacki
- Jacobs Multiple Sclerosis Center, Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Channa Kolb
- Jacobs Multiple Sclerosis Center, Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Multiple Sclerosis Center, Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA. .,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA.
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Jagannath VA, Pucci E, Asokan GV, Robak EW. Percutaneous transluminal angioplasty for treatment of chronic cerebrospinal venous insufficiency (CCSVI) in people with multiple sclerosis. Cochrane Database Syst Rev 2019; 5:CD009903. [PMID: 31150100 PMCID: PMC6543952 DOI: 10.1002/14651858.cd009903.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is a leading cause of neurological disability in young adults. The most widely accepted hypothesis regarding its pathogenesis is that it is an immune-mediated disease. It has been hypothesised that intraluminal defects, compression, or hypoplasia in the internal jugular or azygos veins may be important factors in the pathogenesis of MS. This condition has been named 'chronic cerebrospinal venous insufficiency' (CCSVI). It has been suggested that these intraluminal defects restrict the normal blood flow from the brain and spinal cord, causing the deposition of iron in the brain and the eventual triggering of an auto-immune response. The proposed treatment for CCSVI is venous percutaneous transluminal angioplasty (PTA), which is claimed to improve the blood flow in the brain thereby alleviating some of the symptoms of MS. This is an update of a review first published in 2012. OBJECTIVES To assess the benefit and safety of venous PTA in people with MS and CCSVI. SEARCH METHODS We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group's Specialised Register up to 30 August 2018, CENTRAL (in the Cochrane Library 2018, issue 8), MEDLINE up to 30 August 2018, Embase up to 30 August 2018, metaRegister of Controlled Trials, ClinicalTrials.gov., the Australian New Zealand Clinical Trials Registry, and the World Health Organization (WHO) International Clinical Trials Registry platform. We examined the bibliographies of the included and excluded studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which PTA and sham interventions were compared in adults with MS and CCSVI. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility and risk of bias, and extracted data. We reported results as risk ratios (RR) with 95% confidence intervals (CI). We performed statistical analyses using the random-effects model; and we assessed the certainty of the evidence using GRADE. MAIN RESULTS We included three RCTs (238 participants) in this update. One hundred and thirty-four participants were randomised to PTA and 104 to sham treatment. We attributed low risk of bias to two (67%) studies for sequence generation and two (67%) studies for performance bias. All studies were at a low risk of detection bias, attrition bias, reporting bias and other potential sources of bias.There was moderate-quality evidence to suggest that venous PTA did not increase the proportion of patients who had operative or post-operative serious adverse events compared with the sham procedure (RR 3.33, 95% CI 0.36 to 30.44; 3 studies, 238 participants); nor did it increase the proportion of patients who improved on a functional composite measure including walking control, balance, manual dexterity, postvoid residual urine volume, and visual acuity over 12-month follow-up (RR 0.84, 95% CI 0.55 to 1.30; 1 study, 110 participants); nor did it reduce the proportion of patients who experienced new relapses at six- or 12-month follow-up (RR 0.87, 95% CI 0.51 to 1.49; 3 studies, 235 participants). There was no effect of venous PTA on disability worsening measured by the Expanded Disability Status Scale, which was reported at follow-up intervals of six months (one study), 11 months (one study) and 12 months (one study). Quality of life was reported in two studies with no difference between treatment groups. Moderate or severe pain during or post venography was reported in both PTA and sham-procedure participants in all included studies. Venous PTA was not effective in restoring blood flow assessed at one-month (one study) or 12-month follow-up (one study). AUTHORS' CONCLUSIONS This systematic review identified moderate-quality evidence that, compared with sham procedure, venous PTA intervention did not provide benefit on patient-centred outcomes (disability, physical or cognitive functions, relapses, quality of life) in people with MS. Venous PTA has proven to be a safe technique but in view of the available evidence of its ineffectiveness, this intervention cannot be recommended in people with MS. All ongoing trials were withdrawn or terminated and hence this updated review is conclusive. No further randomised clinical studies are needed.
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Affiliation(s)
- Vanitha A Jagannath
- American Mission HospitalDepartment of PaediatricsManamaManamaBahrainPO Box 1
| | - Eugenio Pucci
- ASUR Marche ‐ Zona Territoriale 9U.O. Neurologia ‐ Ospedale di MacerataVia Santa Lucia, 3MacerataItaly62100
| | - Govindaraj V Asokan
- University of BahrainCollege of Health SciencesSalmaniya Medical ComplexManamaBahrain
| | - Edward W Robak
- MS ConsumerApt 207, 825 McLeod AveFrederictonNBCanadaE3B 9V4
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Jakimovski D, Topolski M, Genovese AV, Weinstock-Guttman B, Zivadinov R. Vascular aspects of multiple sclerosis: emphasis on perfusion and cardiovascular comorbidities. Expert Rev Neurother 2019; 19:445-458. [PMID: 31003583 DOI: 10.1080/14737175.2019.1610394] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic inflammatory, demyelinating, and neurodegenerative disease of the central nervous system. Over the last two decades, more favorable MS long-term outcomes have contributed toward increase in prevalence of the aged MS population. Emergence of age-associated pathology, such as cardiovascular diseases, may interact with the MS pathophysiology and further contribute to disease progression. Areas covered: This review summarizes the cardiovascular involvement in MS pathology, its disease activity, and progression. The cardiovascular health, the presence of various cardiovascular diseases, and their effect on MS cognitive performance are further explored. In similar fashion, the emerging evidence of a higher incidence of extracranial arterial pathology and its association with brain MS pathology are discussed. Finally, the authors outline the methodologies behind specific perfusion magnetic resonance imaging (MRI) and ultrasound Doppler techniques, which allow measurement of disease-specific and age-specific vascular changes in the aging population and MS patients. Expert opinion: Cardiovascular pathology significantly contributes to worse clinical and MRI-derived disease outcomes in MS. Global and regional cerebral hypoperfusion may be associated with poorer physical and cognitive performance. Prevention, improved detection, and treatment of the cardiovascular-based pathology may improve the overall long-term health of MS patients.
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Affiliation(s)
- Dejan Jakimovski
- a Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA.,b Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, The State University of New York , Buffalo , NY , USA
| | - Matthew Topolski
- a Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA
| | - Antonia Valentina Genovese
- a Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA.,c Institute of Radiology, Department of Clinical Surgical Diagnostic and Pediatric Sciences , University of Pavia , Pavia , Italy
| | - Bianca Weinstock-Guttman
- b Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, The State University of New York , Buffalo , NY , USA
| | - Robert Zivadinov
- a Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, State University of New York , Buffalo , NY , USA.,b Jacobs Multiple Sclerosis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences , University at Buffalo, The State University of New York , Buffalo , NY , USA.,d Center for Biomedical Imaging at Clinical Translational Science Institute , University at Buffalo, State University of New York , Buffalo , NY , USA
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Catching the Integration Train: A Look Into the Next 10 Years of Motor-Control and Motor-Learning Research. ACTA ACUST UNITED AC 2018. [DOI: 10.1123/kr.2018-0013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Tarnoki AD, Molnar AA, Tarnoki DL, Littvay L, Medda E, Fagnani C, Arnolfi A, Farina F, Baracchini C, Meneghetti G, Pucci G, Schillaci G, Stazi MA, Nadasy GL. Heritability of the dimensions, compliance and distensibility of the human internal jugular vein wall. PLoS One 2018; 13:e0192948. [PMID: 29561848 PMCID: PMC5862397 DOI: 10.1371/journal.pone.0192948] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 01/18/2018] [Indexed: 11/19/2022] Open
Abstract
Aims The elasticity of the internal jugular vein (IJV) is a major determinant of cerebral venous drainage and right atrium venous return. However, the level of genetic determination of IJV dimensions, compliance and distensibility has not been studied yet. Methods 170 adult Caucasian twins (43 monozygotic [MZ] and 42 dizygotic [DZ] pairs) were involved from the Italian twin registry. Anteroposterior and mediolateral diameters of the IJV were measured bilaterally by ultrasonography. Measurements were made both in the sitting and supine positions, with or without Valsalva maneuver. Univariate quantitative genetic modeling was performed. Results Genetic factors are responsible for 30–70% of the measured properties of IJV at higher venous pressure even after adjustment for age and gender. The highest level of inheritance was found in the supine position regarding compliance (62%) and venous diameter during Valsalva (69%). Environmental and measurement-related factors instead are more important in the sitting position, when the venous pressure is low and the venous lumen is almost collapsed. The range of capacity changes between the lowest and highest intraluminal venous pressure (full distension range) are mainly determined by genetic factors (58%). Conclusions Our study has shown substantial heritability of IJV biomechanics at higher venous pressures even after adjustment for age and gender. These findings yield an important insight to what degree the geometric and elastic properties of the vascular wall are formed by genetic and by environmental factors in humans.
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Affiliation(s)
| | | | | | | | - Emanuela Medda
- Genetic Epidemiology Unit, National Centre of Epidemiology, Istituto Superiore di Sanità, Viale Regina Elena, Rome, Italy
| | - Corrado Fagnani
- Genetic Epidemiology Unit, National Centre of Epidemiology, Istituto Superiore di Sanità, Viale Regina Elena, Rome, Italy
| | - Antonio Arnolfi
- Genetic Epidemiology Unit, National Centre of Epidemiology, Istituto Superiore di Sanità, Viale Regina Elena, Rome, Italy
| | - Filippo Farina
- Department of Neurosciences, University of Padua School of Medicine, Padova, Italy
| | - Claudio Baracchini
- Department of Neurosciences, University of Padua School of Medicine, Padova, Italy
| | - Giorgio Meneghetti
- Department of Neurosciences, University of Padua School of Medicine, Padova, Italy
| | - Giacomo Pucci
- Università di Perugia, Unità di Medicina Interna, Ospedale "S. Maria", Terni, Italy
| | - Giuseppe Schillaci
- Università di Perugia, Unità di Medicina Interna, Ospedale "S. Maria", Terni, Italy
| | - Maria Antonietta Stazi
- Genetic Epidemiology Unit, National Centre of Epidemiology, Istituto Superiore di Sanità, Viale Regina Elena, Rome, Italy
| | - György L. Nadasy
- Department of Physiology, Semmelweis University, Budapest, Hungary
- * E-mail:
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Öner S, Kahraman AS, Özcan C, Özdemir ZM, Ünlü S, Kamışlı Ö, Öner Z. Cerebrospinal Fluid Dynamics in Patients with Multiple Sclerosis: The Role of Phase-Contrast MRI in the Differential Diagnosis of Active and Chronic Disease. Korean J Radiol 2018; 19:72-78. [PMID: 29354002 PMCID: PMC5768510 DOI: 10.3348/kjr.2018.19.1.72] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/07/2017] [Indexed: 11/15/2022] Open
Abstract
Objective Multiple sclerosis (MS) is an inflammatory disease characterized by demyelinating plaques in the white matter. Chronic cerebrospinal venous insufficiency (CCSVI) has been proposed as a new hypothesis for the etiopathogenesis of MS disease. MS-CCSVI includes a significant decrease of cerebrospinal fluid (CSF) flow through the cerebral aqueduct secondary to an impaired venous outflow from the central nervous system. This study aimed to determine whether CSF flow dynamics are affected in MS patients and the contributions to differential diagnosis in active and chronic disease using phase-contrast magnetic resonance imaging (PC-MRI). Materials and Methods We studied 16 MS patients with chronic plaques (group 1), 16 MS patients with active plaques-enhanced on MRI (group 2), and 16 healthy controls (group 3). Quantitatively evaluation of the CSF flow was performed from the level of the cerebral aqueduct by PC-MRI. According to heart rates, 14-30 images were obtained in a cardiac cycle. Cardiac triggering was performed prospectively using finger plethysmography. Results No statistically significant difference was found between the groups regarding average velocity, net forward volume and the average flow (p > 0.05). Compared with the controls, group 1 and group 2, showed a higher peak velocity (5.5 ± 1.4, 4.9 ± 1.0, and 4.3 ± 1.3 cm/sec, respectively; p = 0.040), aqueductal area (5.0 ± 1.3, 4.1 ± 1.5, and 3.1 ± 1.2 mm2, respectively; p = 0.002), forward volume (0.039 ± 0.016, 0.031 ± 0.013, and 0.021 ± 0.010 mL, respectively; p = 0.002) and reverse volume (0.027 ± 0.016, 0.018 ± 0.009, and 0.012 ± 0.006 mL, respectively; p = 0.000). There were no statistical significance between the MS patients with chronic plaques and active plaques except for reverse volume. The MS patients with chronic plaques showed a significantly higher reverse volume (p = 0.000). Conclusion This study indicated that CSF flow is affected in MS patients, contrary to the hypothesis that CCSVI-induced CSF flow decreases in MS patients. These findings may be explained by atrophy-dependent ventricular dilatation, which may occur at every stage of MS.
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Affiliation(s)
- Serkan Öner
- Department of Radiology, Karabük University Faculty of Medicine, Karabük 78050, Turkey
| | | | - Cemal Özcan
- Department of Neurology, İnönü University Faculty of Medicine, Malatya 44280, Turkey
| | - Zeynep Maraş Özdemir
- Department of Radiology, İnönü University Faculty of Medicine, Malatya 44280, Turkey
| | - Serkan Ünlü
- Department of Radiology, Malatya Education and Research Hospital, Malatya 44330, Turkey
| | - Özden Kamışlı
- Department of Neurology, İnönü University Faculty of Medicine, Malatya 44280, Turkey
| | - Zülal Öner
- Department of Anatomy, Karabük University Faculty of Medicine, Karabük 78050, Turkey
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10
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Optimism, enthusiasm, responsibility. J Vasc Surg Venous Lymphat Disord 2017; 5:775-776. [DOI: 10.1016/j.jvsv.2017.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 07/12/2017] [Indexed: 11/22/2022]
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Driedger SM, Maier R, Marrie RA, Brouwers M. Caught in a no-win situation: discussions about CCSVI between persons with multiple sclerosis and their neurologists - a qualitative study. BMC Neurol 2017; 17:176. [PMID: 28882115 PMCID: PMC5590111 DOI: 10.1186/s12883-017-0954-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 08/27/2017] [Indexed: 12/05/2022] Open
Abstract
Background In recent years, shared decision making (SDM) has been promoted as a model to guide interactions between persons with MS and their neurologists to reach mutually satisfying decisions about disease management – generally about deciding treatment courses of prevailing disease modifying therapies. In 2009, Dr. Paolo Zamboni introduced the world to his hypothesis of Chronic Cerebrospinal Venous Insufficiency (CCSVI) as a cause of MS and proposed venous angioplasty (‘liberation therapy’) as a potential therapy. This study explores the discussions that took place between persons with MS (PwMS) and their neurologists about CCSVI against the backdrop of the recent calls for the use of SDM to guide clinical conversations. Methods In 2012, study researchers conducted focus groups with PwMS (n = 69) in Winnipeg, Canada. Interviews with key informants were also carried out with 15 participants across Canada who were stakeholders in the MS community: advocacy organizations, MS clinicians (i.e. neurologists, nurses), clinical researchers, and government health policy makers. Results PwMS reported a variety of experiences when attempting to discuss CCSVI with their neurologist. Some found that there was little effort to engage in desired discussions or were dissatisfied with critical or cautious stances of their neurologist. This led to communication breakdowns, broken relationships, and decisions to autonomously access alternative opinions or liberation therapy. Other participants were appreciative when clinicians engaged them in discussions and were more receptive to more critical appraisals of the evidence. Key informants reported that they too had heard of neurologists who refused to discuss CCSVI with patients and that neurology as a whole had been particularly vilified for their response to the hypothesis. Clinicians indicated that they had shared information as best they could but recommended against seeking liberation therapy. They noted that being respectful of patient emotions, values, and hope were also key to maintaining good relationships. Conclusions While CCSVI proved a challenging context to carry out patient-physician discussions and brought numerous tensions to the surface, following the approach of SDM can minimize the potential for unfortunate outcomes as much as possible because it is based on principles of respect and more two-way communication. Electronic supplementary material The online version of this article (10.1186/s12883-017-0954-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Michelle Driedger
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Ryan Maier
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Melissa Brouwers
- Department of Oncology, McMaster University, Hamilton, ON, Canada
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Kefayati S, Amans M, Faraji F, Ballweber M, Kao E, Ahn S, Meisel K, Halbach V, Saloner D. The manifestation of vortical and secondary flow in the cerebral venous outflow tract: An in vivo MR velocimetry study. J Biomech 2017; 50:180-187. [PMID: 27894675 PMCID: PMC5191981 DOI: 10.1016/j.jbiomech.2016.11.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
Aberrations in flow in the cerebral venous outflow tract (CVOT) have been implicated as the cause of several pathologic conditions including idiopathic intracranial hypertension (IIH), multiple sclerosis (MS), and pulsatile tinnitus (PT). The advent of 4D flow magnetic resonance imaging (4D-flow MRI) has recently allowed researchers to evaluate blood flow patterns in the arterial structures with great success. We utilized similar imaging techniques and found several distinct flow characteristics in the CVOT of subjects with and without lumenal irregularities. We present the flow patterns of 8 out of 38 subjects who have varying heights of the internal jugular bulb and varying lumenal irregularities including stenosis and diverticulum. In the internal jugular vein (IJV) with an elevated jugular bulb (JB), 4Dflow MRI revealed a characteristic spiral flow that was dependent on the level of JB elevation. Vortical flow was also observed in the diverticula of the venous sinuses and IJV. The diversity of flow complexity in the CVOT illustrates the potential importance of hemodynamic investigations in elucidating venous pathologies.
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Affiliation(s)
- Sarah Kefayati
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | - Matthew Amans
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | - Farshid Faraji
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | - Megan Ballweber
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | - Evan Kao
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | | | - Karl Meisel
- Department of Neurology, UCSF, San Francisco, CA, USA
| | - Van Halbach
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | - David Saloner
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA; Radiology Service, VA Medical Center, San Francisco, USA
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Chukanova EI, Mamaeva KI, Chukanova AS. [Treatment of chronic cerebral venous insufficiency: a study on an effect of L-lysine aescinat]. Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:37-41. [PMID: 27500874 DOI: 10.17116/jnevro20161167137-41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To study an effect of L-lysine aescinat on the dynamics of complaints, severity of neurological syndromes and parameters of cerebral blood flow estimated by transcranial doppler and duplex scanning in patients with chronic cerebral venous insufficiency (CCVI). MATERIAL AND METHODS Eighty patients with ultrasound-confirmed CCVI were examined. The basic group included 40 patients who received two treatment courses (intravenous drop-by-drop/stream introductions of L-lysine aescinat in the dose of 5ml during 7 days in 2nd and 30th days of examination). The comparison group consisted of 40 patients. RESULTS AND CONCLUSION Treatment with L-lysine aescinat led to the significant decrease in complaints and improved the scores on the scales used in the study. There was an improvement in the cerebral hemodynamics (an increase of hemodynamic reserve and normalization of the linear blood flow velocity in deep veins) in the patients with CCVI. The safe profile of L-lysine aescinat used in recommended doses was confirmed.
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Affiliation(s)
- E I Chukanova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Kh I Mamaeva
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A S Chukanova
- Pirogov Russian National Research Medical University, Moscow, Russia
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14
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Petolicchio B, Viganò A, di Biase L, Tatulli D, Toscano M, Vicenzini E, Passarelli F, Di Piero V. Cerebral venous hemodynamic abnormalities in episodic and chronic migraine. FUNCTIONAL NEUROLOGY 2016; 31:81-6. [PMID: 27358220 DOI: 10.11138/fneur/2016.31.2.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Alterations of cerebral venous drainage have been demonstrated in chronic migraine (CM), suggesting that cerebral venous hemodynamic abnormalities (CVHAs) play a role in this condition. The aim of the present study was to look for a correlation between CM and CVHAs. We recruited 33 subjects suffering from CM with or without analgesic overuse, 29 episodic migraine (EM) patients with or without aura, and 21 healthy subjects as controls (HCs). CVHAs were evaluated by transcranial and extracranial echo-color Doppler evaluation of five venous hemodynamic parameters. CVHAs were significantly more frequent in the CM and EM patients than in the HCs. In the migraine patients, CVHAs were not correlated with clinical features. The significantly greater frequency of CVHAs observed in the migraineurs may reflect a possible relationship between migraine and these abnormalities. Prospective longitudinal studies are needed to investigate whether CVHAs have a role in the processes of migraine chronification.
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15
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No Association of Chronic Cerebrospinal Venous Insufficiency with Multiple Sclerosis. Can J Neurol Sci 2015; 43:195-7. [PMID: 26194114 DOI: 10.1017/cjn.2015.245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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16
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Krogias C, Gold R, Chan A, Triantafyllou N, Voumvourakis K, Tsivgoulis G. Brain Hyperechogenicities are not Associated with Venous Insufficiency in Multiple Sclerosis: A Pilot Neurosonology Study. J Neuroimaging 2015; 26:150-5. [DOI: 10.1111/jon.12248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 03/02/2015] [Indexed: 01/05/2023] Open
Affiliation(s)
- Christos Krogias
- Department of Neurology, St. Josef-Hospital, Medical Faculty; Ruhr University; Bochum Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Medical Faculty; Ruhr University; Bochum Germany
| | - Andrew Chan
- Department of Neurology, St. Josef-Hospital, Medical Faculty; Ruhr University; Bochum Germany
| | - Nikos Triantafyllou
- 1st Department of Neurology, School of Medicine; University of Athens; Greece
| | | | - Georgios Tsivgoulis
- 2 Department of Neurology, “Attikon” Hospital, School of Medicine; University of Athens; Greece
- International Clinical Research Center, Department of Neurology; St. Anne's University Hospital in Brno; Czech Republic
- Department of Neurology; University of Tennessee Health Science Center; Memphis TN USA
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17
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Viola S, Viola P, Fiorelli L, Buongarzone MP, Litterio P. Transcranial brain photoplethysmography to study the venules of cerebral cortex in patients with multiple sclerosis. Phlebology 2015; 30:119-26. [DOI: 10.1177/0268355513515650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To evaluate the utility of a transcranial brain photoplethysmography parameter as a potential marker for patients with multiple sclerosis. Methods We investigated 38 patients affected by multiple sclerosis, according to the revised McDonald criteria (12 males and 26 females, mean age 41.1 ± 8.5 years, Expanded Disability Status Scale mean value 2.6 ± 2.1) and compared them with 20 age- and sex-matched healthy controls. By means of transcranial brain photoplethysmography, a safe and non-invasive technology, we measured the increase in cerebral blood volume during compression for 10 s of the internal jugular veins of both sides in sitting position. Results The cerebral blood volume increase was significantly smaller in the multiple sclerosis patients (left frontal cortex: −58%, p < 0.0001; right frontal cortex: −59%, p < 0.0001) compared with the controls. Conclusions Our study reveals that a minor increase in cerebral blood volume on the frontal cortex of both sides in sitting position is associated with a diagnosis of multiple sclerosis and might be a new marker.
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Affiliation(s)
- S Viola
- Department of Neurology, S. Pio Hospital, Vasto (CH), Italy
| | - P Viola
- Emergency Medical Service, S.C. De Lellis Hospital, Atessa (CH), Italy
| | - L Fiorelli
- Department of Neurology, S. Pio Hospital, Vasto (CH), Italy
| | - MP Buongarzone
- Department of Neurology, S. Pio Hospital, Vasto (CH), Italy
| | - P Litterio
- Department of Neurology, S. Pio Hospital, Vasto (CH), Italy
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18
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Tsivgoulis G, Faissner S, Voumvourakis K, Katsanos AH, Triantafyllou N, Grigoriadis N, Gold R, Krogias C. "Liberation treatment" for chronic cerebrospinal venous insufficiency in multiple sclerosis: the truth will set you free. Brain Behav 2015; 5:3-12. [PMID: 25722945 PMCID: PMC4321389 DOI: 10.1002/brb3.297] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/19/2014] [Accepted: 10/23/2014] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Chronic cerebrospinal venous insufficiency (CCSVI) has recently been introduced as a chronic state of impaired cerebral or cervical venous drainage that may be causally implicated in multiple sclerosis (MS) pathogenesis. Moreover, percutaneous transluminal angioplasty of extracranial veins termed "Liberation treatment" has been proposed (based on nonrandomized data) as an alternative therapy for MS. METHODS A comprehensive literature search was conducted to identify available published, peer-reviewed, clinical studies evaluating (1) the association of CCSVI with MS, (2) the reproducibility of proposed ultrasound criteria for CCSVI detection (3) the safety and efficacy of "Liberation treatment" in open-label and randomized-controlled trial (RCT) settings. RESULTS There is substantial heterogeneity between ultrasound case-control studies investigating the association of CCSVI and MS. The majority of independent investigators failed to reproduce the initially reported high prevalence rates of CCSVI in MS. The prevalence of extracranial venous stenoses evaluated by other neuroimaging modalities (contrast or MR venography) is similarly low in MS patients and healthy individuals. One small RCT failed to document any benefit in MS patients with CCSVI receiving "Liberation treatment", while an exacerbation of disease activity was observed. "Liberation treatment" has been complicated by serious adverse events (SAEs) in open-label studies (e.g., stroke, internal jugular vein thrombosis, stent migration, hydrocephalus). CONCLUSION CCSVI appears to be a poorly reproducible and clinically irrelevant sonographic construct. "Liberation treatment" has no proven efficacy, may exacerbate underlying disease activity and has been complicated with SAEs. "Liberation treatment" should stop being offered to MS patients even in the settings of RCTs.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens Athens, Greece ; International Clinical Research Center, Department of Neurology, St. Anne's University Hospital Brno, Czech Republic ; Department of Neurology, University of Tennessee Health Science Center Memphis, TN
| | - Simon Faissner
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Germany
| | - Konstantinos Voumvourakis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens Athens, Greece
| | - Aristeidis H Katsanos
- Department of Neurology, School of Medicine, University of Ioannina Ioannina, Greece
| | - Nikos Triantafyllou
- First Department of Neurology, "Eginition" Hospital, School of Medicine, University of Athens Athens, Greece
| | - Nikolaos Grigoriadis
- Department of Neurology, Laboratory of Experimental Neurology and Neuroimmunology, AHEPA Hospital, Aristotle University of Thessaloniki Thessaloniki, Greece
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Germany
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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
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20
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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.
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21
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Jandaghi AB, Amanian D, Roudbari SA, Kanafi AR, Pourghorban R. Evaluation of hemodynamic properties of cerebral venous drainage in patients with multiple sclerosis: a case-control study. Pol J Radiol 2014; 79:323-7. [PMID: 25250100 PMCID: PMC4170839 DOI: 10.12659/pjr.890690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 04/08/2014] [Indexed: 11/09/2022] Open
Abstract
Background The purpose of this study was to compare patients with multiple sclerosis and healthy control subjects as regards hemodynamics of cerebral venous drainage. Material/Methods Between December 2012 and May 2013, 44 consecutive patients with multiple sclerosis and 44 age- and sex-matched healthy subjects underwent the B-mode, color Doppler, and duplex Doppler evaluations of the internal jugular vein (IJV) and vertebral vein. The following four parameters were investigated: IJV stenosis, reversal of postural control of the cerebral venous outflow pathways, absence of detectable blood flow in the IJVs and/or vertebral veins, and reflux in the IJVs and/or vertebral veins in the sitting or supine position. Results In the study group, IJV stenosis, postural control reversal of the cerebral venous outflow pathways, and absence of flow in the IJVs and/or vertebral veins were found in 3 (6.8%), 2 (4.5%), and 3 (6.8%) patients, respectively. In the control group, IJV stenosis (P=0.12), postural control reversal of the cerebral venous outflow pathways (P=0.50), and absence of flow (P=0.12) were not detected. Abnormal reflux was found neither in multiple sclerosis patients nor in healthy subjects. Conclusions No significant difference in the cerebral venous drainage through the IJV or vertebral vein was found between patients with multiple sclerosis and healthy subjects within any of the investigated ultrasonographic parameters.
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Affiliation(s)
- Ali Babaei Jandaghi
- Department of Radiology, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran ; Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Dayan Amanian
- Department of Radiology, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Seyed Ali Roudbari
- Department of Radiology, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | | | - Ramin Pourghorban
- Department of Radiology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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22
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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.
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23
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Siddiqui AH, Zivadinov R, Benedict RHB, Karmon Y, Yu J, Hartney ML, Marr KL, Valnarov V, Kennedy CL, Ramanathan M, Ramasamy DP, Dolic K, Hojnacki DW, Carl E, Levy EI, Hopkins LN, Weinstock-Guttman B. Prospective randomized trial of venous angioplasty in MS (PREMiSe). Neurology 2014; 83:441-9. [PMID: 24975855 DOI: 10.1212/wnl.0000000000000638] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We report the results of the investigation of safety and efficacy of venous angioplasty in patients with multiple sclerosis (MS) with findings of extracranial venous anomalies, considered hallmarks of chronic cerebrospinal venous insufficiency (CCSVI), in a 2-phase study (ClinicalTrials.gov NCT01450072). METHODS Phase 1 was an open-label safety study (10 patients); phase 2 was sham-controlled, randomized, and double-blind (10 sham procedure, 9 treated). All study patients fulfilled venous hemodynamic screening criteria indicative of CCSVI. Assessment was at 1, 3, and 6 months postprocedure with MRI, clinical, and hemodynamic outcomes. Primary endpoints were safety at 24 hours and 1 month, venous outflow restoration >75% at 1 month, and effect of angioplasty on new lesion activity and relapse rate over 6 months. Secondary endpoints included changes in disability, brain volume, cognitive tests, and quality of life. RESULTS No perioperative complications were noted; however, one patient with history of syncope was diagnosed with episodic bradycardia requiring placement of a pacemaker before discharge. Doppler evidence-based venous hemodynamic insufficiency severity score (VHISS) was reduced >75% compared to baseline in phase 1 (at 1 month) but not phase 2. In phase 2, higher MRI activity (cumulative number of new contrast-enhancing lesions [19 vs 3, p = 0.062] and new T2 lesions [17 vs 3, p = 0.066]) and relapse activity (4 vs 1, p = 0.389) were identified as nonsignificant trends in the treated vs sham arm over 6 months. Using analysis of covariance, significant cumulative new T2 lesions were related to larger VHISS decrease (p = 0.028) and angioplasty (p = 0.01) over the follow-up. No differences in other endpoints were detected. CONCLUSION Venous angioplasty is not an effective treatment for MS over the short term and may exacerbate underlying disease activity. CLASSIFICATION OF EVIDENCE This is a Class I study demonstrating that clinical and imaging outcomes are no better or worse in patients with MS identified with venous outflow restriction who receive venous angioplasty compared to sham controls who do not receive angioplasty. This study also includes a Class IV phase 1 study of safety in 10 patients receiving the angioplasty procedure.
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Affiliation(s)
- Adnan H Siddiqui
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY.
| | - Robert Zivadinov
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY.
| | - Ralph H B Benedict
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Yuval Karmon
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Jihnhee Yu
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Mary L Hartney
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Karen L Marr
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Vesela Valnarov
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Cheryl L Kennedy
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Murali Ramanathan
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Deepa P Ramasamy
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Kresimir Dolic
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - David W Hojnacki
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Ellen Carl
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Elad I Levy
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - L Nelson Hopkins
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
| | - Bianca Weinstock-Guttman
- From the Departments of Neurosurgery and Radiology, The Jacobs Neurological Institute (A.H.S., Y.K., M.L.H., E.I.L., L.N.H.), and the Departments of Neurology (R.Z., R.H.B.B., D.W.H., B.W.-G.), Biostatistics (J.Y.), and Pharmaceutical Sciences (M.R.), University at Buffalo, State University of New York; and the Buffalo Neuroimaging Analysis Center (R.Z., K.L.M., V.V., C.L.K., D.P.R., K.D., E.C.), NY
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Tsivgoulis G, Sergentanis TN, Chan A, Voumvourakis K, Triantafyllou N, Psaltopoulou T, Gold R, Krogias C. Chronic cerebrospinal venous insufficiency and multiple sclerosis: a comprehensive meta-analysis of case-control studies. Ther Adv Neurol Disord 2014; 7:114-36. [PMID: 24587827 DOI: 10.1177/1756285613499425] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Chronic cerebrospinal venous insufficiency (CCSVI) has recently been implicated in the pathogenesis of multiple sclerosis (MS). This comprehensive meta-analysis of case-control studies investigates the association of CCSVI with MS. METHODS Through Medline, EMBASE and Cochrane database searches, case-control ultrasound studies comparing CCSVI frequency among patients with MS and healthy controls were identified. RESULTS We identified 19 eligible studies including 1250 patients with MS and 899 healthy controls. The pooled analysis showed that CCSVI was associated with MS [odds ratio (OR) 8.35; 95% confidence interval (CI) 3.44-20.31; p < 0.001) with considerable heterogeneity across studies (I (2) = 80.1%). This association was substantially attenuated in sensitivity analyses excluding studies that were carried out by the group that originally described CCSVI, included investigators who had also been involved in publications advocating endovascular procedures for CCSVI treatment, or were conducted in Italy. Our most conservative sensitivity analysis combining different exclusion criteria yielded no association of CCSVI with MS (OR 1.35; 95% CI 0.62-2.93; p = 0.453) without any heterogeneity (I (2) = 0%). CONCLUSION There is considerable heterogeneity across different case-control studies evaluating the association of CCSVI and MS. The greatest factor contributing to this heterogeneity appears to be the involvement of investigators in other publications supporting endovascular procedures as a novel MS treatment.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, 'Attikon' Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece and International Clinical Research Center, St Anne's University Hospital Brno, Brno, Czech Republic
| | - Theodoros N Sergentanis
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, University of Athens, Athens, Greece
| | - Andrew Chan
- Department of Neurology, Ruhr University, St Josef-Hospital, Bochum, Germany
| | - Konstantinos Voumvourakis
- Second Department of Neurology, 'Attikon' Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Nikos Triantafyllou
- First Department of Neurology, 'Eginition' Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, University of Athens, Athens, Greece
| | - Ralf Gold
- Department of Neurology, Ruhr University, St Josef-Hospital, Bochum, Germany
| | - Christos Krogias
- Department of Neurology, Ruhr University, St Josef-Hospital, Bochum, Germany
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Jedynak W, Cieszanowski A. Is there any relation between chronic cerebrospinal venous insufficiency and multiple sclerosis? - a critical review. Pol J Radiol 2014; 79:131-6. [PMID: 24917892 PMCID: PMC4049975 DOI: 10.12659/pjr.890379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 02/03/2014] [Indexed: 11/17/2022] Open
Abstract
Summary Though the etiology of multiple sclerosis remains unknown, the widely accepted explanation is that it has an autoimmune inflammatory background. In 2006 Paolo Zamboni renewed the somewhat forgotten vascular theory of the pathogenesis of multiple sclerosis, proposing the new entity of 'chronic cerebrospinal venous insufficiency'. As a result of this hypothesis, Zamboni suggested an endovascular treatment for multiple sclerosis involving venoplasty of the internal jugular vein and the azygos vein. Unfortunately, several teams have tried to replicate Zamboni's results without success. In this review, we present a chronological description of the results of the studies conducted by Zamboni and the later attempts to replicate his work. The main conclusion is that, taking into account results that are currently available, we should remain cautious and routine use of this treatment in patients should not be advisable.
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Affiliation(s)
- Waldemar Jedynak
- Department of Diagnostic Imaging, Hospital of the West, Jan Paul II, Grodzisk Mazowiecki, Poland
| | - Andrzej Cieszanowski
- 2 Department of Radiology, Laboratory of Magnetic Resonance, Medical University of Warsaw, Warsaw, Poland
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Spagnolo S, Scalise F, Barbato L, Grasso MA, Tesler UF. Bilateral surgical reconstruction for internal jugular veins disease in patients with chronic cerebrospinal venous insufficiency and associated multiple sclerosis. Ann Vasc Surg 2014; 28:1793.e1-4. [PMID: 24704584 DOI: 10.1016/j.avsg.2014.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 03/18/2014] [Accepted: 03/19/2014] [Indexed: 10/25/2022]
Abstract
Chronic cerebrospinal venous insufficiency (CCSVI) is a vascular condition characterized by morphologic alterations involving efferent cerebral vascular paths. CCSVI has been implicated as a contributing factor to multiple sclerosis (MS) but this theory is highly controversial. We report 3 cases of CCSVI patients with MS who had undergone internal jugular veins (IJVs) angioplasty to restore vessels patency. All patients reported significant symptomatic improvement after angioplasty until symptoms recurred after restenosis of the treated IJVs. Surgical IJVs reconstruction was performed. Patients' symptoms gradually improved and the benefits were maintained at the 1-year follow-up.
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Affiliation(s)
- Salvatore Spagnolo
- Department of Cardiac and Vascular Surgery, Policlinico di Monza, Monza, Italy; Cardiac and Vascular Catheterization Laboratory, Policlinico di Monza, Monza, Italy; CCSVI Research Center, Policlinico di Monza, Monza, Italy
| | - Filippo Scalise
- Cardiac and Vascular Catheterization Laboratory, Policlinico di Monza, Monza, Italy; CCSVI Research Center, Policlinico di Monza, Monza, Italy.
| | - Luciano Barbato
- Department of Cardiac and Vascular Surgery, Policlinico di Monza, Monza, Italy; Cardiac and Vascular Catheterization Laboratory, Policlinico di Monza, Monza, Italy; CCSVI Research Center, Policlinico di Monza, Monza, Italy
| | | | - Ugo F Tesler
- Department of Cardiac and Vascular Surgery, Policlinico di Monza, Monza, Italy; Cardiac and Vascular Catheterization Laboratory, Policlinico di Monza, Monza, Italy; CCSVI Research Center, Policlinico di Monza, Monza, Italy
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Baracchini C. Libera nos a malo. J Neurol Neurosurg Psychiatry 2014; 85:361. [PMID: 24039029 DOI: 10.1136/jnnp-2013-305925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Monti L, Menci E, Piu P, Leonini S, Arrigucci U, Bellini M, Zandonella A, Galluzzi P, Casasco A. A sonographic quantitative cutoff value of cerebral venous outflow in neurologic diseases: a blinded study of 115 subjects. AJNR Am J Neuroradiol 2014; 35:1381-6. [PMID: 24610905 DOI: 10.3174/ajnr.a3864] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND PURPOSE The autonomic nervous system maintains constant cerebral venous blood outflow in changing positions. Alterations in cerebral autoregulation can be revealed by postural changes at quantitative color Doppler sonography. The aim of this study was to reach an optimal cutoff value of the difference between the cerebral venous blood outflow in the supine and seated positions that can discriminate healthy controls from patients with multiple sclerosis and those with other neurologic diseases and to evaluate its specificity, sensitivity, and diagnostic accuracy. MATERIALS AND METHODS One hundred fifteen subjects (54 with MS, 31 healthy controls, 30 with other neurologic diseases) underwent a blinded quantitative color Doppler sonography evaluation of cerebral venous blood outflow in the supine and sitting positions. An optimal difference value between the supine and sitting positions of the cerebral venous blood outflow cutoff value was sought. RESULTS The difference value between supine and sitting positions of the cerebral venous blood outflow was ≤ 503.24 in 38/54 (70.37%) patients with MS, 9/31 (29.03%) healthy controls, and 13/30 (43.33%) subjects with other neurological diseases. A difference value between supine and sitting positions of the cerebral venous blood outflow at a 503.24 cutoff reached a sensitivity at 70.37%, a 70.96% specificity, a 80.85% positive predictive value, and a 57.89% negative predictive value; the quantitative color Doppler sonography parameters yielded significant differences. The difference value between supine and sitting positions of cerebral venous blood outflow ≤ 503.24 assessed the significant difference between MS versus other neurological diseases. CONCLUSIONS Alteration of cerebral venous blood outflow discriminated MS versus other neurologic diseases and MS versus healthy controls. The difference value between supine and sitting positions of cerebral venous blood outflow ≤ 503.24 was statistically associated with MS.
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Affiliation(s)
- L Monti
- From the Unit of Neuroimaging and Neurointervention (L.M., E.M., S.L., U.A., M.B., A.Z., P.G.), Department of Neurological and Sensorial Sciences, Azienda Ospedaliera Universitaria Senese, Santa Maria alle Scotte General Hospital, Siena, Italy
| | - E Menci
- From the Unit of Neuroimaging and Neurointervention (L.M., E.M., S.L., U.A., M.B., A.Z., P.G.), Department of Neurological and Sensorial Sciences, Azienda Ospedaliera Universitaria Senese, Santa Maria alle Scotte General Hospital, Siena, Italy
| | - P Piu
- Department of Medicine, Surgery and Neuroscience (P.P.), University of Siena, Siena, Italy
| | - S Leonini
- From the Unit of Neuroimaging and Neurointervention (L.M., E.M., S.L., U.A., M.B., A.Z., P.G.), Department of Neurological and Sensorial Sciences, Azienda Ospedaliera Universitaria Senese, Santa Maria alle Scotte General Hospital, Siena, Italy
| | - U Arrigucci
- From the Unit of Neuroimaging and Neurointervention (L.M., E.M., S.L., U.A., M.B., A.Z., P.G.), Department of Neurological and Sensorial Sciences, Azienda Ospedaliera Universitaria Senese, Santa Maria alle Scotte General Hospital, Siena, Italy
| | - M Bellini
- From the Unit of Neuroimaging and Neurointervention (L.M., E.M., S.L., U.A., M.B., A.Z., P.G.), Department of Neurological and Sensorial Sciences, Azienda Ospedaliera Universitaria Senese, Santa Maria alle Scotte General Hospital, Siena, Italy
| | - A Zandonella
- From the Unit of Neuroimaging and Neurointervention (L.M., E.M., S.L., U.A., M.B., A.Z., P.G.), Department of Neurological and Sensorial Sciences, Azienda Ospedaliera Universitaria Senese, Santa Maria alle Scotte General Hospital, Siena, Italy
| | - P Galluzzi
- From the Unit of Neuroimaging and Neurointervention (L.M., E.M., S.L., U.A., M.B., A.Z., P.G.), Department of Neurological and Sensorial Sciences, Azienda Ospedaliera Universitaria Senese, Santa Maria alle Scotte General Hospital, Siena, Italy
| | - A Casasco
- Unit of Endovascular and Percutaneous Therapy (A.C.), Clinica Nuestra Señora del Rosario, Madrid, Spain
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Jurkiewicz E, Kotulska K, Nowak K, Chełstowska S, Armata M, Chmielewski D, Bilska M. MR venography in children and adolescents with multiple sclerosis does not show increased prevalence of extracranial veins anomalies. Eur J Paediatr Neurol 2014; 18:218-22. [PMID: 24411179 DOI: 10.1016/j.ejpn.2013.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 11/14/2013] [Accepted: 11/24/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system that affects mainly young adults, but can occur also in children and adolescents. The pathogenesis of MS is still not fully understood and chronic cerebrospinal venous insufficiency (CCSVI) was suggested to be implicated in MS. Although there is no strong evidence to support this hypothesis, a considerable number of MS patients, including adolescents, have undergone endovascular treatment procedures. The aim of this study was the evaluate the prevalence of extracranial venous system anomalies in children and adolescents with multiple sclerosis in comparison to age-matched controls. MATERIAL AND METHODS Twenty-one children with clinically definite diagnosis of MS (mean age 13.8 years), and 19 age-matched controls (mean age 12.5 years) were investigated using 1.5 T scanner with coronal 3D contrast-enhanced coronal venography. The diameters of internal jugular veins (IJV) at both sides of the neck were estimated separately, from the level C1 to Th1. RESULTS Anomalies of the extracranial venous system were found in 10 MS patients (47.6%) and 13 controls (68.4%). Normal anatomy of extracranial veins was recognized in 11 MS patients (53%) and 6 controls (31%). Comparison of the measurement results for MS patients and the control group revealed that there are no significant statistical differences in cross-section areas for a given level. CONCLUSIONS We found no evidence to suggest that MS children and adolescents have more extracranial veins anomalies than healthy patients. Considering the risk of such treatment, endovascular interventions should be discourage.
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Affiliation(s)
- Elżbieta Jurkiewicz
- Department of Diagnostic Imaging, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Katarzyna Kotulska
- Department of Neurology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Katarzyna Nowak
- Department of Diagnostic Imaging, The Children's Memorial Health Institute, Warsaw, Poland
| | - Sylwia Chełstowska
- Department of Diagnostic Imaging, The Children's Memorial Health Institute, Warsaw, Poland
| | - Michał Armata
- Department of Diagnostic Imaging, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dariusz Chmielewski
- Department of Neurology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Małgorzata Bilska
- Department of Neurology, The Children's Memorial Health Institute, Warsaw, Poland
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Sudau F, Friede T, Grabowski J, Koschack J, Makedonski P, Himmel W. Sources of information and behavioral patterns in online health forums: observational study. J Med Internet Res 2014; 16:e10. [PMID: 24425598 PMCID: PMC3958625 DOI: 10.2196/jmir.2875] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/24/2013] [Accepted: 11/11/2013] [Indexed: 11/30/2022] Open
Abstract
Background Increasing numbers of patients are raising their voice in online forums. This shift is welcome as an act of patient autonomy, reflected in the term “expert patient”. At the same time, there is considerable concern that patients can be easily misguided by pseudoscientific research and debate. Little is known about the sources of information used in health-related online forums, how users apply this information, and how they behave in such forums. Objective The intent of the study was to identify (1) the sources of information used in online health-related forums, and (2) the roles and behavior of active forum visitors in introducing and disseminating this information. Methods This observational study used the largest German multiple sclerosis (MS) online forum as a database, analyzing the user debate about the recently proposed and controversial Chronic Cerebrospinal Venous Insufficiency (CCSVI) hypothesis. After extracting all posts and then filtering relevant CCSVI posts between 01 January 2008 and 17 August 2012, we first identified hyperlinks to scientific publications and other information sources used or referenced in the posts. Employing k-means clustering, we then analyzed the users’ preference for sources of information and their general posting habits. Results Of 139,912 posts from 11,997 threads, 8628 posts discussed or at least mentioned CCSVI. We detected hyperlinks pointing to CCSVI-related scientific publications in 31 posts. In contrast, 2829 different URLs were posted to the forum, most frequently referring to social media, such as YouTube or Facebook. We identified a total of 6 different roles of hyperlink posters including Social Media Fans, Organization Followers, and Balanced Source Users. Apart from the large and nonspecific residual category of the “average user”, several specific behavior patterns were identified, such as the small but relevant groups of CCSVI-Focused Responders or CCSVI Activators. Conclusions The bulk of the observed contributions were not based on scientific results, but on various social media sources. These sources seem to contain mostly opinions and personal experience. A small group of people with distinct behavioral patterns played a core role in fuelling the discussion about CCSVI.
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Affiliation(s)
- Fabian Sudau
- Institute of Computer Science, Georg-August-University Göttingen, Göttingen, Germany.
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Affiliation(s)
- Friedemann Paul
- NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany.
| | - Mike P Wattjes
- MS Center Amsterdam, Department of Radiology, Nuclear Medicine, and PET Research, VU University Medical Center, Amsterdam, Netherlands
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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.
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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.
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Using existing data to identify candidate items for a health state classification system in multiple sclerosis. Qual Life Res 2013; 23:1445-57. [PMID: 24338161 DOI: 10.1007/s11136-013-0604-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2013] [Indexed: 02/03/2023]
Abstract
PURPOSE In multiple sclerosis (MS), the use of preference-based measures is limited to generic measures such as Health Utilities Index Mark 2 and 3, the EQ-5D and the SF-6D. However, the challenge of using such generic preference-based measures in people with MS is that they may not capture all domains of health relevant to the disease. Therefore, the main aim of this paper is to describe the development of a health state classification system for MS patients. The specific objectives are: (1) to identify items best reflecting the domains of quality of life important to people with MS and (2) to provide evidence for the discriminative capacity of the response options by cross-walking onto a visual analog scale of health rating. METHODS The data come from an epidemiologically sampled population of people with MS diagnosed post-1994. The dataset consisted of 206 items relating to impairments, activity limitations, participation restrictions, health perception and quality of life. Important domains were identified from the responses to the Patient Generated Index, an individualized measure of quality of life. The extent to which the items formed a uni-dimensional, linear construct was estimated using Rasch analysis, and the best item was selected using the threshold map. RESULTS The sample was young (mean age 43) and predominantly female (n = 140/189; 74%). The P-PBMSI classification system consisted of five items, with three response levels per item, producing a total of 243 possible health states. Regression coefficient values consistently decreased between response levels and the linear test for trend were statistically significant for all items. The linear test for trend indicated that for each item the response options provided the same discriminative ability within the magnitude of their capacity. A scoring algorithm was estimated using a simple additive formula. The classification system demonstrated convergent validity against other measures of similar constructs and known-groups validity between different clinical subgroups. CONCLUSION This study produced a health state classifier system based on items impacted upon by MS, and demonstrated the potential to discriminate the health impact of the disease.
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Laughlin S, Macgowan CK, Traubici J, Chan K, Khan S, Arnold DL, Marrie RA, Banwell B. No evidence for impairment of venous hemodynamics in children or young adults with pediatric-onset multiple sclerosis. AJNR Am J Neuroradiol 2013; 34:2366-72. [PMID: 23868149 DOI: 10.3174/ajnr.a3661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Chronic cerebrospinal venous insufficiency is a postulated etiologic factor for multiple sclerosis, but the higher frequency with longer disease duration and progressive disability suggests that chronic cerebrospinal venous insufficiency is secondary to chronic disease. We evaluated the presence of chronic cerebrospinal venous insufficiency in pediatric-onset MS. MATERIALS AND METHODS Twenty-six pediatric patients with MS (18 years of age or younger), 26 age-matched healthy controls, and 13 young adults with pediatric-onset MS underwent sonography of the internal jugular, vertebral, and deep cerebral veins. Five venous hemodynamic criteria were assessed, with 2 criteria required for chronic cerebrospinal venous insufficiency. MR imaging studies, performed in the pediatric patients with MS and healthy control groups, included intracranial 2D time-of-flight MR venography and velocity-sensitive phase-contrast sequences. Contrast-enhanced brain MR images were obtained in pediatric patients with MS to further evaluate venous patency. We used paired t tests, Wilcoxon matched pairs, McNemar tests, and exact conditional logistic regression to estimate the association of chronic cerebrospinal venous insufficiency with MS. RESULTS Fifty participants (73.5%) had normal ultrasound findings, 15 (23.1%) met 1 venous hemodynamic criterion, and 2 pediatric patients with MS and 1 young adult with pediatric-onset MS met chronic cerebrospinal venous insufficiency criteria. Chronic cerebrospinal venous insufficiency was not associated with MS (odds ratio, 2.41; 95% CI, 0.19-infinity). Demographic and disease characteristics did not differ between the patients with MS meeting chronic cerebrospinal venous insufficiency criteria (n = 3) and those who did not (n = 36; all, P > .05). The mean (SD) MR imaging measures of intracerebral flow did not differ between the 2 pediatric patients with MS meeting chronic cerebrospinal venous insufficiency criteria (0.85 ± 0.11) and healthy controls (0.87 ± 0.16, P = .50); no child demonstrated venous obstruction. CONCLUSIONS Chronic cerebrospinal venous insufficiency is rarely observed in children or young adults with pediatric-onset MS. Venous anatomy and flow rates indicate that venous outflow is intact in pediatric patients with MS. Our findings argue against chronic cerebrospinal venous insufficiency as a component of MS etiology.
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What is the relationship between chronic cerebrospinal venous insufficiency and multiple sclerosis? ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.rvm.2013.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Karmon Y, Ramanathan M, Minagar A, Zivadinov R, Weinstock-Guttman B. Arterial, venous and other vascular risk factors in multiple sclerosis. Neurol Res 2013; 34:754-60. [PMID: 22971465 DOI: 10.1179/1743132812y.0000000077] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Yuval Karmon
- The Jacobs Neurological Institute Department of Neurology, University at Buffalo, , State University of New York, Buffalo, NY, USA
| | - Murali Ramanathan
- Department of Pharmaceutical SciencesState University of New York, Buffalo, NY, USA
| | - Alireza Minagar
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Robert Zivadinov
- The Jacobs Neurological Institute Department of Neurology, University at Buffalo, , State University of New York, Buffalo, NY, USA
- Buffalo Neuroimaging Analysis CenterState University of New York, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- The Jacobs Neurological Institute Department of Neurology, University at Buffalo, , State University of New York, Buffalo, NY, USA
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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.
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Affiliation(s)
- Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, USA.
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Chronic cerebrospinal venous insufficiency is unlikely to be a direct trigger of multiple sclerosis. Mult Scler Relat Disord 2013; 2:334-9. [PMID: 25877843 DOI: 10.1016/j.msard.2013.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Revised: 01/31/2013] [Accepted: 02/12/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Chronic cerebrospinal venous insufficiency, a vascular pathology affecting the veins draining the central nervous system can accompany multiple sclerosis and is suspected to be involved in its pathogenesis. OBJECTIVE This study was aimed at exploring a potential role for chronic cerebrospinal venous insufficiency in triggering multiple sclerosis. If it were venous abnormalities responsible for neurological pathology, one should expect negative correlation, i.e. more severe vascular lesions in the patients with early onset of multiple sclerosis. METHODS Localization and degree of venous blockages in 350 multiple sclerosis patients were assessed using catheter venography. Statistical analysis comprised evaluation of the correlations between severity of venous lesions and patients' age at onset of the disease. RESULTS We found weak, yet statistically significant positive correlations between patients' age at onset of multiple sclerosis and accumulated and maximal scores of venous lesions. The patients, also those with duration of multiple sclerosis not longer than 5 years, who had their first attack of the disease at younger age, presented with less severe vascular lesions. CONCLUSION Positive correlation suggests that venous lesions are not directly triggering multiple sclerosis. There should be another factor that initiates pathological processes in the central nervous system.
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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
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Chambers B, Chambers J, Churilov L, Cameron H, Macdonell R. Internal jugular and vertebral vein volume flow in patients with clinically isolated syndrome or mild multiple sclerosis and healthy controls: results from a prospective sonographer-blinded study. Phlebology 2013; 29:528-35. [PMID: 24065289 DOI: 10.1177/0268355513505505] [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: 11/15/2022]
Abstract
OBJECTIVES & METHODS We evaluated internal jugular vein and vertebral vein volume flow using ultrasound, in patients with clinically isolated syndrome or mild multiple sclerosis and controls, to determine whether volume flow was different between the two groups. RESULTS In patients and controls, internal jugular vein volume flow increased from superior to inferior segments, consistent with recruitment from collateral veins. Internal jugular vein and vertebral vein volume flow were greater on the right in supine and sitting positions. Internal jugular vein volume flow was higher in the supine posture. Vertebral vein volume flow was higher in the sitting posture. Regression analyses of cube root transformed volume flow data, adjusted for supine/sitting, right/left and internal jugular vein/vertebral vein, revealed no significant difference in volume flow in patients compared to controls. CONCLUSIONS Our findings further refute the concept of venous obstruction as a causal factor in the pathogenesis of multiple sclerosis. Control volume flow data may provide useful normative reference values.
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Affiliation(s)
- Brian Chambers
- Department of Neurology, Austin Health, Melbourne, Australia The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia Department of Medicine, University of Melbourne, Victoria, Australia
| | - Jayne Chambers
- Department of Neurology, Austin Health, Melbourne, Australia
| | - Leonid Churilov
- The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia Department of Mathematics and Statistics, University of Melbourne, Victoria, Australia
| | - Heather Cameron
- Department of Neurology, Austin Health, Melbourne, Australia
| | - Richard Macdonell
- Department of Neurology, Austin Health, Melbourne, Australia The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia Department of Medicine, University of Melbourne, Victoria, Australia
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Zwischenberger BA, Beasley MM, Davenport DL, Xenos ES. Meta-Analysis of the Correlation Between Chronic Cerebrospinal Venous Insufficiency and Multiple Sclerosis. Vasc Endovascular Surg 2013; 47:620-4. [DOI: 10.1177/1538574413503562] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Purpose: To determine whether a correlation exists between chronic cerebrospinal venous insufficiency (CCSVI) and multiple sclerosis (MS). Materials and Methods: A meta-analysis of the current literature was performed to evaluate the frequency of CCSVI, diagnosed by echo color Doppler criteria, in patients with MS and in normal controls. Results: In all, 19 studies were identified from January 2005 through February 2013; however, 3 studies were excluded due to duplicate data and 3 additional studies because 0 patients fulfilled CCSVI criteria in both MS and control groups. In order to improve homogeneity, 4 outlier studies were also removed from the analysis. Analysis of the remaining 9 studies demonstrated a significant correlation between CCSVI and MS (odds ratio 1.885, P < .0001) with no significant heterogeneity of the studies ( I2 = 18, P = .279). Conclusions: The meta-analysis demonstrated a correlation between CCSVI and MS. However, there was no evidence that CCSVI has a causative role in MS.
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Affiliation(s)
| | - Mary M. Beasley
- College of Medicine, University of Kentucky, Lexington, KY, USA
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Lochner P, Nedelmann M, Kaps M, Stolz E. Jugular Valve Incompetence in Transient Global Amnesia. A Problem Revisited. J Neuroimaging 2013; 24:479-83. [DOI: 10.1111/jon.12042] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 05/07/2013] [Accepted: 05/09/2013] [Indexed: 11/30/2022] Open
Affiliation(s)
- Piergiorgio Lochner
- Department of Neurology; Justus-Liebig University; Giessen Germany
- Department of Neurology; Krankenhaus Meran; Meran Italy
| | - Max Nedelmann
- Department of Neurology; Justus-Liebig University; Giessen Germany
| | - Manfred Kaps
- Department of Neurology; Justus-Liebig University; Giessen Germany
| | - Erwin Stolz
- Department of Neurology; Caritasklinikum Saarbruecken; Saarbruecken Germany
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No evidence for CCVSI in relapsing-remitting multiple sclerosis patients with moderate disability. J Neurol 2013; 260:2409-10. [DOI: 10.1007/s00415-013-7034-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 06/29/2013] [Indexed: 10/26/2022]
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ElSankari S, Balédent O, van Pesch V, Sindic C, de Broqueville Q, Duprez T. Concomitant analysis of arterial, venous, and CSF flows using phase-contrast MRI: a quantitative comparison between MS patients and healthy controls. J Cereb Blood Flow Metab 2013; 33:1314-21. [PMID: 23778162 PMCID: PMC3764393 DOI: 10.1038/jcbfm.2013.95] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 04/16/2013] [Accepted: 04/17/2013] [Indexed: 01/30/2023]
Abstract
Venous dysfunction has recently been hypothesized to contribute to the pathophysiology of multiple sclerosis (MS). 2D phase-contrast (PC) magnetic resonance imaging (MRI) is a non-invasive and innocuous technique enabling reliable quantification of cerebrospinal fluid (CSF) and blood flows in the same imaging session. We compared PC-MRI measurements of CSF, arterial and venous flows in MS patients to those from a normative cohort of healthy controls (HC). Nineteen MS patients underwent a standardized MR protocol for cerebral examination on a 3T system including Fast cine PC-MRI sequences with peripheral gating in four acquisition planes. Quantitative data were processed using a homemade software to extract CSF and blood flow regions of interest, animate flows, and calculate cervical and intracranial vascular flow curves during the cardiac cycle (CC). Results were compared with values obtained in 21 HC using multivariate analysis. Venous flow patterns were comparable in both groups without signs of reflux. Arterial flows (P=0.02) and cervical CSF dynamic oscillations (P=0.01) were decreased in MS patients. No significant differences in venous cerebral and cervical outflows were observed between groups, thereby contradicting the recently proposed theory of venous insufficiency. Unexpected decrease in arterial perfusion in MS patients warrants further correlation to volumetric measurements of the brain.
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Affiliation(s)
- Souraya ElSankari
- Department of Neurology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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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.
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Affiliation(s)
- Tommaso Lupattelli
- Vascular and Endovascular Unit, Istituto Clinico Cardiologico (ICC) Gruppo Villa Maria (GVM) Sanità, Rome, Italy.
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Laukontaus SJ, Kagayama T, Lepäntalo M, Atula S, Färkkilä M, Albäck A, Inoue Y, Tienari P, Venermo M. Doppler ultrasound examination of multiple sclerosis patients and control participants: inter-observer agreement and association with disease. Eur J Vasc Endovasc Surg 2013; 46:466-72. [PMID: 23920002 DOI: 10.1016/j.ejvs.2013.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 07/05/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Chronic cerebrospinal venous insufficiency (CCSVI) has been proposed as a major risk factor for multiple sclerosis (MS). The aim of this study was to assess inter-observer agreement between two ultrasound examiners and to compare findings in MS patients and control participants. METHODS A prospective, blinded, controlled study of MS patients diagnosed within 2 years (MS ≤ 2, n = 39), patients diagnosed more than 10 years ago (MS > 10, n = 43) and age- and sex-matched control participants (n = 40). Ultrasound examinations were performed by two independent examiners. CCSVI criteria 1, 3, 4 and 5 as proposed by Zamboni were explored: (1) reflux in the internal jugular (IJV) and vertebral veins (VV), (3) IJV cross-sectional area (CSA) ≤0.3 cm(2), (4) absence of flow in IJV and VV, and (5) reverted postural control of venous outflow. RESULTS Criteria 1, 4 and 5 were met in less than 10% of the MS patients and control participants as studied by both examiners. The level of inter-observer agreement was poor for all parameters except assessment of the CSA of IJV at the thyroid level. Findings meeting CCSVI criterion 3 (CSA ≤ 0.3 cm(2)) were observed in 18/40 (45%) of the control participants, in 24/37 (65%) of MS ≤ 2 patients (p = 0.09 vs. control participants) and in 30/43 (70%) of the MS > 10 patients (p = 0.022 vs. control participants). CONCLUSIONS The feasibility of the CCSVI criteria for common use is questionable because of low inter-observer agreement. Small-calibre IJVs meeting the CCSVI criterion 3 appear common in both Finnish control participants and MS patients, but the clinical significance of this finding is questionable.
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Affiliation(s)
- S J Laukontaus
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Imperiale D, Melis F, Giaccone C, Guido M, Milano E, Buffa C, Appendino L. Chronic cerebrospinal venous insufficiency in multiple sclerosis: A sonographer-blinded case-control study. Clin Neurol Neurosurg 2013; 115:1394-8. [PMID: 23384545 DOI: 10.1016/j.clineuro.2013.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/09/2013] [Accepted: 01/10/2013] [Indexed: 01/21/2023]
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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.
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Affiliation(s)
- Ralph H B Benedict
- Department of Neurology, State University of New York at Buffalo, 100 High St, Buffalo, NY 14203, USA.
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Krsmanović Ž, Živković M, Lepić T, Stanković A, Raičević R, Dinčić E. Small internal jugular veins with restricted outflow are associated with severe multiple sclerosis: a sonographer-blinded, case-control ultrasound study. BMC Neurol 2013; 13:90. [PMID: 23865501 PMCID: PMC3734033 DOI: 10.1186/1471-2377-13-90] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 07/12/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent evidence has indicated an association between chronic cerebrospinal venous insufficiency (CCSVI) and multiple sclerosis. Small internal jugular veins (IJVs) (with a cross-sectional area of less than 0.4 cm²) have been previously described as difficult to catheterize, and their presence may potentially affect cerebrospinal venous drainage. In this blinded extracranial color-Doppler study we had two principal aims: first, to assess prevalence of CCSVI among Serbian MS patients compared to healthy controls; and second, to assess prevalence of small IJVs (with a CSA ≤ 0.4 cm²) among MS patients and controls. METHODS The sixty seven unrelated patients with clinical isolated syndrome (CIS), relapsing-remitting (RR), secondary progressive (SP) and primary progressive (PP) multiple sclerosis and 21 healthy controls were examined by high-resolution color-Doppler. RESULTS The ultrasonographic criteria of CCSVI (according to Zamboni) were positive in 11.9% of the patients and in none of the control subjects. The CCSVI-positive patients had significantly longer disease durations and were significantly more disabled (measured by their Expanded Disability Status Scale (EDSS) and Multiple Sclerosis Severity Score (MSSS) scores), but after adjustment for gender and disease duration, CCSVI was not an independent risk factor for multiple sclerosis severity. The small IJVs were found in 28.4% of the patients and 28.6% of the controls. The patients with small IJVs were associated with decreased venous outflow from the brain and presented with longer disease durations and significantly higher EDSS and MSSS scores compared to patients without small IJVs. A multivariate logistic regression analysis adjusted for gender and disease duration showed that small IJV is an independent factor associated with multiple sclerosis severity (EDSS ≥6) (adjusted OR = 8.9, 95% CI: 1.8-45.6, p = 0.007). Among patients with small IJVs the 36.84% were also CCSVI positive. CONCLUSIONS Both, CCSVI and small IJVs seem to influence or follow MS severity, but only small IJVs turned out to be an independent factor in this study. Thus, small IJVs with restricted outflow, which might be aspects of CCSVI different from the criteria originally described by Zamboni, emerge as a cofactor in the multifactorial pathophysiology of multiple sclerosis.
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Zamboni P, Sisini F, Menegatti E, Taibi A, Malagoni AM, Morovic S, Gambaccini M. An ultrasound model to calculate the brain blood outflow through collateral vessels: a pilot study. BMC Neurol 2013; 13:81. [PMID: 23845008 PMCID: PMC3720253 DOI: 10.1186/1471-2377-13-81] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 07/05/2013] [Indexed: 12/23/2022] Open
Abstract
Background The quantification of the flow returning from the head through the cervical veins and the collaterals of the internal jugular vein (IJV), is becoming of prominent interest in clinical practice. We developed a novel model to calculate the cerebral venous return, normalized to the arterial inflow, in the different segments of the IJV. Methods We assessed, by established Echo Colour Doppler (ECD) methodology, the head inflow (HBinF) defined as the sum of common carotids and vertebral arteries, as well as the cerebral flow (CBF) defined as the sum of internal carotid and vertebral arteries. We also assessed the head outflow (HBoutF) defined as the sum of the measurements at the junction of the IJV and the vertebral veins. In addition, we also calculated the collateral flow index (CFI) by estimating the flow which re-enters directly into the superior vena cava as the amount of blood extrapolated by the difference between the HBinF and the HBoutF. We preliminarily tested the model by comparing ten healthy controls (HC) with ten patients affected by chronic cerebral spinal venous insufficiency (CCSVI), a condition characterized by some blockages in the IJV which are bypassed by collateral circulation. Results In HC the HBinF was 956+-105ml/min, whereas the HBoutF was > 90% of the HBinF, leading to a final CFI value of 1%. The last result shows that a very small amount of blood is drained by the collaterals. In upright we confirmed a reduction of the outflow through the IJV which increased CFI to 9%. When we applied the model to CCSVI, the HBinF was not significantly different from controls. In supine, the flow of CCSVI patients in the IJV junction was significantly lower (p < 0.001) while the correspondent CFI value significantly increased (61%, p < 0.0002). Conclusions Our preliminary application of the novel model in the clinical setting suggests the pivotal role of the collateral network in draining the blood into the superior vena cava under CCSVI condition.
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Affiliation(s)
- Paolo Zamboni
- Vascular Diseases Center, University of Ferrara, Cona, (FE), Italy.
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